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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 9537697 FOR INSPECTIONS r' EXPIRES 1 YEAR FROM DATE ISSUE[ JOB ADDRESS J�aSS(o S �-1-�o ,r y M0`' CITY/ZIP d akd,7 (- 94 CROSS STREET �� .f <ti AP IN Al i' AA 0W PARCEL SIZE J OWNERNAME Plctsetle;e, 3 Lr' /CD_ -z e Z L PHONE /+ OWNER ADDRESS .1' Q CITY/STATE/ZIP CONTRACTOR Ivn ( i_ /S��< ��J�L L i< PHONE L� L� G G� CONTRACTOR ADDRESS— y 7� � ,a CITY/STATE/ZIP ' ZVI-44� rrS ,��, LICENSE 11L -C-42 ❑I .0-36 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 D REPAIR/ADDITION C ENGINEER DESIGNED /ALTERNATIVE I I REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM l DESTRUCTION INSTALLATION WILL SERVE: a--rEsIDENCE ❑ COMMERCIAL ❑ OTHER /NUMBER OF LIVING UNITS: n �) NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: r� � SEPTIC TANK TYPE/MFG Y iT L CAPACITY/7AI # CSF (.nMPARTMFNT...1 ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL / ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY gal # OF COMPARTMENTS ft FOUNDATIONI ft PROPERTY LINE ft . ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) EACH LINES LJ LEACHING CHAMBERS Received y # OF LINES 3 LENGTH OF LINES t ft Amount Remitted DISTANCE TO NEAREST WELL ft FOUNDATION �ZS 1 It PROPERTY LINE '751 ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft 5 3 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 � � Q�SEEPAGEPITS NUMBER 3 WIDTH ft DEPTH �S I ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE -7 5 ft 1 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. SIGNED TITLE DATE DEPARTMENT U E ONLY Application Accepted y �— Date IT3 0? Area y Cf-/ n Employee ID# Final Inspection By Date fE,T 202'L-❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: R Q-A ep -} Pit/Sump Soil Character: COMMENTS Snc6)ylI (.�WPI�I?✓tr, 71Pr .Il 02f7-1'Ppnli, VI) — lJ I-. PE Code SC INFO Received y Check#/ Cash Amount Remitted Date Permit/ ervice R quest # Invoice # Permit ID# 1-0 0 ►» 5 3 �a �� 12 Ip 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18