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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-KEFUNDABLE PERMIT GALL (ZpUY)JY03-/6y/ FOR INSPECTIONS �M tXPIRES "I Y EAR FKUgM UAI E 155/uEl JOB ADDRESS q ;.�J I L S 1"L rQ 1 Ao � / CITY/ZIP I • 1 CI�G� .1e- A` ) -T- 1?1_ CROSS STREET _ 14"1 S 7'{ /� /�Q.D APN d0 Q 0011?PARCEL SIZE I. L / OWNER NAME DpH101 / 'Kill rtZ PHONE OWNER ADDRESS Selp"e CITY/STATE/ZIP �y p CONTRACTOR �� I % IS CGf A 1 PHONE Li 4 lO 0 CONTRACTOR ADDRESS & 64& (e / y CITY/STATE/ZIP j' l an j- C_4 / G✓! TS Z-� LICENSE ❑cC-42 ❑ :C-36 OTHER �J NUMBER (eVDJ.i -1 EXPIRATION DATE .I06_"a/ /:. WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION _ REPAIRIADDITION L ENGINEER DESIGNED /ALTERNATIVE it REPLACEMENT OUT -0F -SERVICE SEPTIC SYSTEM i. DESTRUCTION INSTALLATION WILL SERVE: WIRESIDENCE ❑ COMMERCIAL? ❑ OTHER NUMBER OF LIVING UNITS: � NUMBER OF BEDROOMS: v 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 l_I LEACHING CHAMBERS yaio # OF LINES LENGTH OF LINES ft -"FILTER DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft P' BED WIDTH �a ft LENGTH a-7�� ft DEPTH &t4ble_ Qe40f% ft DISTANCE TO NEAREST WELL / tj(�) ft FOUNDATION ({j I ft PROPERTY LINE 8✓ 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. Iq IIVIl IIWIVI -►V IIVVI\ J -1L., VjV3/V%,L- /VV I1lrL RC V11\GIJ VVIR IIY/J�r�CV I /V/VJ - r1_GF10C V/`1LL LV: SIGNED TITLE-�OC�ic C- DATE DEPARTMENT U E ONLY I Application Accepted By C fi Date -21311-R& Area Employee ID#_0` \7 Final Inspection By o Date 2-� 5 ter "1-L ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: LJ Pit/Sump Soil Character: COMMENTS ()nc�ef�>(r'�Ine vn-re ��r• T,'Qr dF Feloe4. I)iG fw-a Ime-Ig Rhes Fbr hevul S4IU(+Vfe gha f -o ?veel seth' eicks {Ctor., evsh')?i I"o]. PE Code SC INFO Received By Check#/ ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# yaio 115- sia 3 ZZ 42-01 . %I �� / //� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 T '-1