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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 (:ALL ZUyyySJ-/by/ FOR INSPECTIONS LXPIRES I YEAR FROM LATE ISSUE[ JOB ADDRESS C DJ S / CITY/ZIP CROSS STREET l r c l^ N r�^ e APN O 17/ L3 0 L� PARCEL SIZE OWNER NAME Sl.la F'`+Ci r t P I y 3 ��%��C; I C� v /iG 1 � 'P I/� PHONE OWNER ADDRESS J �I Q C % J P p cl / -CITY/STATE/ZIP LL, )I ), d(-� ;? CONTRACTOR i/V1li PHONE CONTRACTOR ADDRESS d'-, �\c f.( C_6� CITY/STATE/ZIP �► lG/(I�Gf}- � G•J ` �z� LICENSE C-42 ❑UC -36 OTHER NUMBE EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION L�"REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE U REPLACEMENT OUT -0F -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: 4, ESIDENCE C COMMERCIAL C OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) U, -LEACH LINES LEACHING CHAMBERS Received B # OF LINES LENGTH OF LINES L& ft Amount Remitted DISTANCE TO NEAREST WELL ft FOUNDATION (Lj I ft PROPERTY LINE �j) I ft ❑ FILTER BED WIDTH ft LENG H >>S 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 n SEEPAGE PITS b'I DISTANCE TO NEAREST WELL NUMBER WIDTH ft Q FOUNDATION ft PROPERTY LINE ft ft DEPTH ft DISTANCE TO NEAREST WELL A ft FOUNDATION 16'' ft PROPERTY LINE �a� ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ND 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 REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED ' _'CA TITLE GaYN�i�cG r DATE % ;-;)-- DEPARTMENT USE ONLY r I' Application Accepted By_�__.., ��—�` L— Date 7 Area -I Employee ID# F("I Final Inspection By GDza -Z Date -L� 23-'- SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS -fIPT L 'tl;�+iY'�' PE Code SC INFO Received B / Cash Amount Remitted Service Request # Invoice # Permit ID# qal o >>S VPermitl 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18