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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 NON-REFUNDABLE PERMIT GALL 2U9 Y53-/6y/FOR INSPECTIONS tXcPIIRRES l YEAR FROM UA IF I55UEI JOB ADDRESS I �{i}1�- ` f�� w �' �,J - CITY/ZIP �G t-{�-�� r v iL� CIS -2-3-1 1 /� CROSS STREET I+•"�' v� n p �jAPN C0' ' - 2 -9y -GS PARCELSIZESIZE -I �'�Q�y!"�-'C OWNER NAME TIM S,I M?31-7--f /SEGO ` ler`--nEJ PHONE S -q /- Ct3 + OWNER ADDRESS v�05 S ',K�'�S�E� • r(--�q-� CITY/STATE/ZIP �� I CA C -'Y - `—T o CONTRACTOR Irl ) tT 0.��yC�O �J�i �tI+t—�` Y��J� I f �� PHONE 3('29 —03-1 S A. CONTRACTOR ADDRESS C �' t�K " - CRY/STATE/ZIP �� I GY t �- Lj C: LICENSE ❑CIC -42 ❑I.IC.36 OTHER CC&- NUMBER �(1 ` EXPIRATION DATE-�G-Zz WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # 14 BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: is NEW INSTALLATION I REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE WIDTH I7 REPLACEMENT Ci OUT -OF -SERVICE SEPTIC SYSTEM II DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: WIDTH ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ SUMPS DISTANCETo NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEbL ❑ LEACH LINES l LEACHING CHAMBERS Amount Date Remitted # OF LINES DISTANCE TO NEAREST WELL aO ft FOUNDATION_ ❑ FILTER BED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION _ ❑ MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL It FOUNDATION _ ❑ SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION _ ❑ DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION_ ❑ SEEPAGE PITS NUMBER WIDTH DISTANCE To NEAREST WELL ft FOUNDATION _ LENGTH OF LINES Ttzc ft PROPERTY LINE // ft ft DEPTH M4 Ad ftp ft PROPERTY LINE ft DEPTH /ft!/ ft PROPERTY LINE1 Nl/[jD�`Tl�/ ft DEPTH I T/I n ft PROPERTY LINE 111 ft DEPTH ft T ft PROPERTY LINE ft ft DEPTH ft 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. MINIMUM 0 /OUR, ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE ("-03- M C'2 - DATE ----------------- Application Accepted By Final Inspection By + Character of Soil to Depth of 3 Ft: COMMENTS .uw moraanen Dv.aa.�..-...� � d,• p0� it ♦ —_. _� SE ONLY r� Zea ( Employee ID# ❑ SPECIAL PERMIT -Approved by Pit/Sump Soil Character: 0 ■ PE Code Sc Received Che INFO Amount Date Remitted PermiU Invoice # Permit ID# Service Re uest # - -7 d . �{ 22 aO 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4114/18 4 to Y °o A If 2022 ti-?-..