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11 1 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 Ill..2 '�r�'�_� H JA_J p CITY/ZIP �-S It ,174--&l/f C.C.[ Z n q CROSS STREET APN O p G O I PARCEL SIZE/�/[, fl 7 /.J C OWNER NAME R/7 r/ /-p ��` /�� l PHONE 20 OWNER ADDRESS �O S,1�� CITY/STATE/ZIP CONTRACTOR f,yy [ (� `� PHONE © [� �� O7 5-C _ CONTRACTOR ADDRESS �� ba 44-, -) Yi -{%CY CITY/STATE/ZIP LICENSE ❑11C-42 11I..1C-36 OTHER NUMBER EXPIRATION DA WATER TABLE DEPTH: n(,no ft GEOGRAPHICAL INFORMATION: Coordinates X )IVO zC) Y `� O U ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ' NEW INSTALLATION ❑ REPAIR/ADDITION L ENGINEER DESIGNED /ALTERNATIVE 11 REPLACEMENT 11 OUT -0F -SERVICE SEPTIC SYSTEM CJ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL P� $ ❑ OTHER NUMBER OF LIVING UNITS: wNUMBER OF BEDROOMS: I?NUMBER OF EMPLOYEES: /7 SEPTIC TANK TYPF/MFC; /V/ I A7 L /) CAPACITY /I AP / -f Oi / nal # CIF C(IMPARTMFNTR L GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL LIFT STATION SIZE TYPE OF PUMP CAPACITY gal # OF COMPARTMENTS � ft FOUNDATION J J ' ft PROPERTY LINE j-�' / ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) L/ LEACH LINES LEACHING CHAMBERS_ # OF LINES 3 LENGTH OF LINES ft DISTANCE TO NEAREST WELL 1L5; ft FOUNDATION _ft PROPERTY LINE ft FILTER BED WIDTH ft LENGTH Check#/ Cash ft DEPTH _ ft Date DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft MOUNDED WIDTH ft LENGTH gay 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 3(, ft DEPTH as ft DISTANCE TO NEAREST WELL 150 ft t FOUNDATION 1 (7O t 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, 1.11TIM Wiwi - u I IWWI I n✓ V1.1IVWL IV I IWL IAC 6/IRCLJ rWrc IIYJ!'CV I IWIVO - r-1-CHJC l.diLL I Lual vua-/ oy/ SIGNED TITLE © i/ DATE /� Z Z DEPARTMENT USjE ONLY G ft Application Accepted By. Lel_ Date �6 .?ate Area Y/ `� Employee IIA64M. tel Final Inspection By Date Z ❑ SPECIAL PERMIT -Approved Character of Soil to Depth of Ft: Pit/Sump Soil Character: COMMENTS tuleln/ 6K. I " er a NEP I c .P1 4% PE Code SC INFO Received By Check#/ Cash Amount Remitted Date Permit/ Service equest # Invoice # Permit T a� 1 i►�1 gay S 42-01 OO �+ l� I ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18