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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 (:ALL (ZUyl) Y:0-10YI FOR INSPECTIONS eXPIHtS I T tAH 1 -HUM uA I t I,SUt JOB ADDRESS I ZS %- , r LOG )'�-E F- J , CITY/ZIP LG C-KiE JP7 �S (T]/� CROSS STREET • OU APN �S - 2-10 -G8 PARCELSIZE -I�.0 A -C. T OWNER NAME IM s'II'Y\iS o -N! SECo PAA PELT►ES PHONE S-17-)- 9.3" l OWNER ADDRESS C. --TbA1 S�- / , , G • ( CITY/STATE/ZIP LaD I S y4 CONTRACTOR L -I \J C O LACY b ,AJ >,/ II�I YYI ENi1PCL PHONE 3&9 `031 CONTRACTOR ADDRESS 44r'-1 w • 0 4-sK- &T • CITY/STATE/ZIP WZ> I C�^ / Ll V LICENSE LI'- C-42 C71.'C-36 OTHER CE C7- NUMBER 2I 1�-, EXPIRATION DATE 4 _:�G -2'7- WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION _. ENGINEER DESIGNED/ALTERNATIVE ,_# VVCC REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM -. DESTRUCTION INSTALLATION WILL SERVE: J 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 ft DEPTH Y ft 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 V � DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ,_# VVCC ❑ FILTER BED WIDTH ft LENGTH ft DEPTH I� A/ fly DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE- W 0 i0^ L3 MOUNDED MOUNDED WIDTH ft LENGTH ft DEPTH Y ft ` DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE_ X(N jp L- e 7"1 CO/ I EI SUMPS WIDTH ft LENGTH ft DEPTH TH nVNA� �TAV� T� DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE PN TMrENT ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It 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. J& 11$2UR ADVANCE NOTICE R / R INSPECTIONS - PLEASE CALL (209) 953-7697 �y-� ' �2 1- 12- ZZ SIGNED TITLE ioc�ruxm. ue. • DATE ------------ ------------- ---.a� .. GK� a �T"a Application Accepted By Date Final Inspection By y I I y Date_ Character of Soil to Depth of 3 Ft: COMMENTS IS -9 ONLY q Z?rea 1 Employee ID# SPECIAL PERMIT - Approved by Pit/Sump Soil Character: PE SC Received Che Amount Date Permit/ Invoice # Permit ID# Code INFO Remitted Service Re uest # 0z, 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18