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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 TYPE/MFG ��Yl GALLZU.9.95J-76.97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS/�� �'C/�JyJwc� �� CITY/ZIP gal # OF COMPARTMENTS FOUNDATION_ DISTANCE TO NEAREST: WELL %C'C' C s I I CROSS STREET ❑ LIFT STATION SIZE TYPE OF PUMP APN PARCEL SIZE OWNERNAME �I(IlE��JS_�fC^,r_) ��, �C�IFS ��f'7i) PHONE OWNER ADDRESS-CITY/STATE/ZIP FOUNDATION ft PROPERTY LINE ft CONTRACTOR L� "/rte -9G ��/��yJ ��— PHONE c� CONTRACTOR ADDRESS �� / / �y��w ft %%%/�� CITY/STATE/ZIP DISTANCE TO NEAREST LICENSE ❑k-42 ❑❑C-36 OTHER NUMBER EXPIRATION DATE 12% WATER TABLE DEPTH: - I O ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # d 1 o3s-0:1 LAND USE APPLICATION # TYPE OF WORK: r• NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: Z SEPTIC TANK TYPE/MFG ��Yl CAPACITY gal # OF COMPARTMENTS Z- ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS FOUNDATION_ DISTANCE TO NEAREST: WELL %C'C' ft FOUNDATION /L ft PROPERTY LINE h`: ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES ❑ LEACHING CHAMBERS # OF LINES % LENGTH OF LINES _ s S ft ate DISTANCE TO NEAREST WELL /1 ft FOUNDATION_ O� _ft PROPERTYLINE_ ft ❑ FILTER BED WIDTH ft LENGTH 1i 21 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 FO�UUNDATION ft PROPERTY LINE ft 16 SEEPAGE PITS NUMBER I WIDTH y ;1 ft DEPTH 2; ft DISTANCE TO NEAREST WELL / S L 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 RE IRED FOR INSPECTIONS - PLEASE CALL 209) 953-7697 SIGNED G-�� 7 Y;-J�i--" TITLE l �' DATE � DEPARTMEN T U 'E ONLY r ._l I( jam, Application Accepted Bye " L- Date u�J Area C/ Employee ID# Final Inspection By Date 1 SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS �C�<_� �o/ tDC b("Tf?YDD r +o rirc &,-. ��Fr L= N w (G C'N V- r' cy j O 1� 6� l VI � 2- c -j EP T -Lz -2--z- PE 2-2 PE Code Sc INFO Received By eck#/ ash Amount Remitted ate Permit/ Service Request # Invoice # Permit ID# y�11 }1-7Z +S:? 1i 21 � ! WFl- 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 T