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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-REFUNDABLE PER/MIT CALL ,2J09 953-7697 FOR INSPECTIONS^ /EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS C, �1 CITY/ZIP :2 �%19 ��•S7CROSS STREET erI�yS APN. p^A. _ OWNER NAME /C-1 "C La Lv��1// PHONE --Z� 1 -7 OWNER ADDRESS S-6a�r�0 u/ ` f��' CITY/STATE/ZIP CONTRACTOR <- PHONE _ t CONTRACTOR ADDRESS LICENSE A C-42 J C-36 OTHER CITY/STATE/ZIP NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION ❑ PERC TEST # BUILDING PERMIT # Coordinates X Y LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION}U A INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: TERNATIVE ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS Permit ID# DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ 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 ❑ 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 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. McI-NNiMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED /�/�c/ TITLE CEJ %1-�� DATE ff DEPARTMEN U E ONLY ""ufNDEPART,0`_ Application Accepted B �_ v<' Date S 3 d Area Employee ID# V� Final Inspection By Date t{r uj Z J ( ! SPE IAL P RM IT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS ,Dewlto 4 S iru c4u re. PE Code Sc INFO Received By thaaw Cash Amount Remitted Date Permit/ Service est # Invoice # Permit ID# as ass �° 32 sa 42 -01 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 VA -