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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 ivvrv-r[trUNUHtSLt rtt<Ml I GALL ZU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE] JOB ADDRESS 21'7 (r 2 S. �d rra 160 Rel CITY/ZIP '. a vt 3 o CROSS STREET R j V e/ i�O u e( LI NEW INSTALLATION a APNty�► �I PARCEL SIZE d h '7 OWNERNAME50QAS4H '. � OUT -0F -SERVICE SEPTIC SYSTEM PHONE? -7-9—y(%00 OWNER ADDRESS Jr Dt �(iQs-4- /�fy [ 2 Q CITYISTATE/ZIP • IQ �t ��C f� I Ool- S -3..7L CONTRACTOR'0r4 1 T f !qyL s 6j 17tA (, NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: PHONE 2 og - (P-2 3 — 1L_I y lI CONTRACTOR ADDRESS P. O • 13,1,' 10 7 TYPE/MFG CITY/STATE/ZIP p LICENSE k'C-42 ❑f ;C-36 OTHER A ❑ /vo NUMBER 73 EXPIRATION DATE 12 -3( 20P 3 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y Check#/ Amount Cash Remitted ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # ya)s TYPE OF WORK: LI NEW INSTALLATION a REPAIR/ADDITION -_ ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT J.,Za& �j e(c, I OUT -0F -SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ;�- COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 3 LEACH LINES LI LEACHING CHAMBERS # of LINES LENGTH OF LINES_ ft DISTANCE TO NEAREST WELL ft FOUNDATION gQ ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It 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. SIGNED ,�_ JZ —�� TITLE I - ro j e c (- /r �tL[KAR .Ar DATE j�/ 3/ Z!J Z Z- DEPARTMENT U E ONLY _� Application Accepted By �/— l�� Date 33 a � Area S Employee ID# Final Inspection By Date Date ❑ SPECIAL PERMIT -Approved by 0 Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS Per (-,0rf r' Cfyr /!N)�S ,i d � be iOO '60;v� reser ;-f. Conc,re+e linec1 rchCl1 J �e Ark IMF)) lFt'C Celci &7 a (ac 1G C-0:a)Ylg>✓ar e.ielf free ryo I&P s$U/ c f12FI(Mil.5iin r ! i'e cbo olo PE Code SC INFO Received B Check#/ Amount Cash Remitted ate Permit/ Service Re uest # Invoice # Permit ID# ya)s y *4/ 42-01 C•n{` .iYC 114 -7 7 5 T ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18