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f ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUNDABLLE PERMIT /' [(:ALLL (ZUY YbJ-1bY1 FOR INSPECTIONS,y� LXPIRES 1 YEAR FROM DATE ISSUE] JOB ADDRESS ' ✓ 3' /ti i - l�'��'� J t�J p CITY/ZIP CROSSSTREET �n�- (� APN ��+ 070 ^ /3 PARCEL SIZE OWNER NAME /lO�1%, l2�','L4 Y � cY dV � V / ' PHONE OWNER ADDRESS L D%C U'07 CITY/STATE/ZIP T CONTRACTOR 164I?L �• PHONE Ll �� D�,r J a CONTRACTOR ADDRESS -X(lY (//1 �u CITY/STATE/ZIPG A /.sG K} 1611' / E,3 3 LICENSE ❑LIC -42 01IC-36 OTHER NUMBER EXPIRATION DATE a6 a h )= WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT #0e D Z%& LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE Permit/ Service Request # REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG P J, L �� L f lf-L CAPACITY 'I:: C) Z) gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS c� /- DISTANCE TO NEAREST: WELL / jj ft FOUNDATION I O ft PROPERTY LINE 7 J ft �a ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 0,1 FILTER BED WIDTH I a ft LENGTH GG 1 n I ft DEPTH 18 I ft DISTANCE TO NEAREST WELL ft FOUNDATION I�j t ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE C-6✓I ce-,f-, C DATES 1aZ Vr S /y UI CT E f T r DEPARTMENT USEIONLY p 2Z Area ( Employee ID# j� ' �/1'«"•s• Application Accepted By Date Final Inspection By ( Date 2 ❑ SP CIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: /Pit/Sump Soil Character: COMMENTS 1,41 So ,�.z PE Code SC INFO Received B Check ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# y� 11 3 Zz c� 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18