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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-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 7��M S �Y�`� et -D,, fz\,)ei�i CITY/ZIP ��}t'n CROSS STREET j ^�1( Y' p' iL� 1 r� T \e %V' j( NA 1 S -7a 3 o a LI PARCEL SIZE O/ i ( -7 OWNER NAME PHONE m OWNER ADDRESS Z �^ Z 2O S V CITY/STATE/ZIPS //C. �`* �r CA, \s -z 1 CONTRACTOR O�� IA PHONE �� bZc) O!S CONTRACTOR ADDRESS �O S Vl 1 N\V CITY/STATE/ZIP V'1 �e-�iT C' 0, \ S 71 LICENSE EhZ-42 []#C-36 OTHER NUMBER ' : EXPIRATION DATE \ ) WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION I ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM 1k DESTRUCTION f4jM k INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP ft CAPACITY CAPACITY FOUNDATION ❑ PKG TX PLANT ❑ gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft ❑ 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. SIGNEDi//+– %-'i✓*/�-•- TITLE `/ / „ MSR _ DATE DEPARTMENT USE ONLY Application Accept By — Date Area 1 Employee ID#ln� Final Inspection B Date ��\A�`�.�/ ElSPECIAL PERMIT - Approved by Character of Soil to epth of 3 Ft: Pit/Sump Soil Charac er: COMMENTS ccy--tV1Jib 6e n-» r .Srl,./P.r, PcC�-(� c,t��(� ,�, p„@ S ti,o w z.1J �. (� �r� � �`� W �.� � ?J V.. •G � R L � .'��- T�v PE Code SC INFO Received py Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18