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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUNDABLE PERMIT E;ALL ZU'J 903-/b'J/ FOR INSPECTIONS LX IRES 7 YEAR FROM UATE ISSUEI JOB ADDRESS/�'�3 ` c� CITY/ZIP �7 CROSS STREET / q 1 Pa t/e f o APN 0 6 3 — ) 7 0 ~ / PARCEL SIZE /' ? D OWNER NAME PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTORlJw� T ]" PHONE v 6 I IC✓//,,� / ^ �/� / CONTRACTOR ADDRESS a ti �Q� CITY/STATE/ZIP LICENSE ❑\�(C-42 ❑' 'C-36 OTHER NUMBER / EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION J ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -0F -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL NUMBER OF LIVING UNITS: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION NUMBER OF BEDROOMS: 3 ❑ OTHER NUMBER OF EMPLOYEES: TYPE/MFG /-S�1 C� CAPACITY gal # OF COMPARTMENTS TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft SIZE TYPE OF PUMP L1 PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 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. IV111WIVIVIVI '/o r7VVrx /YLJ VP7IYVL IYV I ILrL RC VIRLL/ rV/x IIV17r LV II V/r e7 - rLL.P%JL I LVJ JJJ-11 U.71 SIGNED /GlT TITLE �aC 011 DATE "CZ2 -� DEPARTMENT U E NLY Application Accepted Bq— Date Area/� CJ Employee ID# Final Inspection By Date 7r o1 ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3t: Pit/Sump Soil Character: COMMENTS PE Code LEACH LINES ILEACHING CHAMBERS Check#/ Amount Da a Cash ,Remitted Permit/ Invoice # Permit ID# Service Request # # OF LINES LENGTH OF LINES i °� ' ft DISTANCE TO NEAREST WELL ft FOUNDATION /OO ft PROPERTY LINE lS ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION 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 TON A��77REST WELL ft FOUNDATION ft PROPERRTTY-LINE ft SEEPAGE PITS NUMBER ; WIDTH 17q L/ ft DEPTH o�J ft DISTANCE TO 6AREST WELL I -"C ✓ ft FOUNDATION -5-61 ft PROPERTY LINE t !/V 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. IV111WIVIVIVI '/o r7VVrx /YLJ VP7IYVL IYV I ILrL RC VIRLL/ rV/x IIV17r LV II V/r e7 - rLL.P%JL I LVJ JJJ-11 U.71 SIGNED /GlT TITLE �aC 011 DATE "CZ2 -� DEPARTMENT U E NLY Application Accepted Bq— Date Area/� CJ Employee ID# Final Inspection By Date 7r o1 ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3t: Pit/Sump Soil Character: COMMENTS PE Code SC INFO Received By Check#/ Amount Da a Cash ,Remitted Permit/ Invoice # Permit ID# Service Request # q21,0y2� /157 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18