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i ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE-STOCKTON CA 95205 -(209) 468-3420 NON-KEFUNDABLE PERMIT GALL ILUNJ `J06 -/Da/ FOR INSPEG!IONS CAPIKts T T t_AK I-KUM UAIt: ISJUt Jos ADDRESS `12 5y ;I \ Y 1 Cm/ZIP CROSS STREET'''{' V6'er'na' O Vt APN UOS 3-/ PARCELSIZE 33 OWNER NAME J o'n�-�'cl a �a c PHONE OWNERADDRESS - CITY/STATE/LP �" C*'�n , CONTRACTOR �eS1C J� PHONE '� o`� - 33C► -1' tt1 CONTRACTOR ADDRESS • T T X V"� /�I S� q CR(� Y/STATE/ZIP `A '1'5 2-q kD LICENSE _ C42 . , C-36 OTHER P -r NUMBER uEXPRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIRIADDITIONENGINEER DESIGNED IALTERNATNE WIDTH REPLACEMENT OUTOFSERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: --RESIDENCE I COMMERCIAL Z ! OTHER NUMBER OF LNWG 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) LEACH LINES *—LEACHING CHAMBERS 1YN-�A �Q4 �R� #OF LINES , LENGTH OF LINES DISTANCE TO NEAREST WELL M 011 9- R FOUNDATION ft PROPERTY UNE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE 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 It 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 `Z WIDTH) ft DEPTH 2s ft DISTANCE TO NEAREST WELL NJiTC 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 TITLE i\ DATE T' DEPARTMENT USE ONLY Application Accepted By - Date_ �a s/ v% � Area T -! GJ Employee ID# Final Inspection By Date _ G SPECIAL PERMIT - Approved by Character of Soil to Depth f 3 Ft: PIt/Sump So I Character: / ' COMMENTS PCJfjr✓Wi11,rCJ 'tier ( St'LfiUil 5,ej % Cofren f SfGNG%rrrs, repel 11' 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18