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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 FERMIT (:AL ZU9) 953-1091 FOR INSPECTIONS tXPIREES 'I YEARFROMUATE ISSUEI JOB ADDRESS / / CITY/ZIP�r!� Yj- f e % CROSS STREET A ��d�!' AP /.g ` ©%U - ©Z PARCEL SIZE • OWNER NAMEl J��L YI K /PGS IJ I1 / PHONE OWNER ADDRESS / / �_ /(�� J" � CITY/STATE/ZIP CONTRACTOR % Ll`�,"/J/�)�/7� % 4 PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE L7! '1;-42 ❑ 'C-36 OTHER NUMBER / v w EXPIRATION DATE �✓ 3/ .2 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION_ REPAIR/ADDITION [i ENGINEER DESIGNED /ALTERNATIVE �// REPLACEMENT T1" +� I OUT -OF -SERVICE SEPTIC SYSTEM X DESTRUCTION t6lll< INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG t t ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP ❑ LEACH LINES LEACHING CHAMBERS # OF LINES DISTANCE TO NEAREST WELL ❑ FILTER BED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ❑ MOUNDED WIDTH ft FOUNDATION DISTANCE TO NEAREST WELL ❑ SUMPS WIDTH ft DISTANCE TO NEAREST WELL ❑ DISPOSAL PONDS WIDTH ft DISTANCE TO NEAREST WELL ❑ SEEPAGE PITS NUMBER LENGTH DISTANCE TO NEAREST WELL CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft LENGTH OF LINES _ ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE 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 ADVA CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNEDX // TITLE %%!/lylls �y B ft DEPARTMENT U E ONLY Application Accepted i Date 7 �� Area Ciq Employee ID# AG _ Final Inspection By Date/3 %(^/L)ftCrL2 ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS 3_�C, PE Code Sc INFO # OF LINES hec Cash Amount Remitted ft FOUNDATION Invoice # LENGTH 901 1 I s ft 27 ft FOUNDATION SPON53I LENGTH ft ft FOUNDATION LENGTH ft ft FOUNDATION LENGTH ft ft FOUNDATION WIDTH ft FOUNDATION ft LENGTH OF LINES _ ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE 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 ADVA CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNEDX // TITLE %%!/lylls �y B ft DEPARTMENT U E ONLY Application Accepted i Date 7 �� Area Ciq Employee ID# AG _ Final Inspection By Date/3 %(^/L)ftCrL2 ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS 3_�C, PE Code Sc INFO Received By hec Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 901 1 I s 27 �302 12 SPON53I 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 T