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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT 4SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT j� ' `C�ALLL/ 209 953-7697 FOR INSPECTIONS 1 EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS � ?71U �i l�Pv V`'J�v 1 CITY/ZIP _ &I��C� 5331 LA 741 CROSS STREET W�M I � `/� V�`'(7-, IDj�� ' { /& APN a o 0H O O 6 PARCEL 'SnIZ4E Q�3Q: �aj� o OWNER NAME '1�� /1"iY L'iWY I"`✓��1 E"///��Z6 OWNER ADDRE�SS ✓Il��j��f�T��f��I,'l P- /�bLAI D 2-0D CITY/STATE/ZIZIP(�`' 1,�,�n"'`� ,CA 1�iq4�D-7 CONTRACTOR 1"' bD✓ ✓+ +'�`-'1) � ela ti" `�`�� I Q & PHONE 'q I W 21 3 I � J CONTRACTOR ADDRESS LP 1�7 NSM M�Tf �U�T CITY/STATE/ZIP / LICENSE ❑I!C-42 [111 IC 36 OTHER ell 2- 4 Cel NUMBER211 I I LOU EXPIRATION DATE 02- �� `C)7,✓2 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED//ALTERNA�TIVVE��/f REPLACEMENT OUT-0 �1 ►F-SERVICE SEPTIC SYSTEM r DESTRUCTIONALl L, /T 444 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) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH 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 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. MINIMUM48HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE,\CALL 209 95 -76R7 SIGNED TITLEfMS�'�lJ G u� DATE 4—THerw R A F1 I XC N IR N E T E R M N / DEPARTMENT USE ONLY /! // Application Accepted By zL% Date �y �� , Area 3 m��1+t« Employee ID# A V Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 t: Pit/Sump Soil Character: COMMENTS Dewy b{ -<,I-f le evy)'Js un r f' bf h�jl* fo bf- d fet mMea PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B Cash Remitted Service Request# as 1 0�� Js� tit 45 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18