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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) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS -T' / % z led /�/i CITY/ZIPS/l�ctl✓t/[l `V �../n_/I/ G 4%,:]�'�[ S CROSS STREET �1711�1 AJ T a Ex /e d l f of j; 1q 3 ' 3 n PARCEL SIZE to OWNER NAMEr r7 iY11WA 1Z. ofj;y PHONEipCiL'� OWNER ADDRESS �L7 P �' I u p wf Cr o 7 + I ! CITY/STATE/ZIP ,-544-_ � "[ u , b CONTRACTOR 1 e-'7 PHONE CONTRACTOR ADDRESS / �i{ �f�f4. CITY/STATE/ZIP LICENSE pC 42 ❑❑C-36 OTHERNUMBER 70 EXPIRATION DATE) WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: ❑ PERC TEST # BUILDING PERMIT #' a10 TYPE OF WORK: ❑ NEW INSTALLATION , ❑ REPAIR/ADDIT Coordinates X Y_ J% LAND USE APPLICATION # )N ❑ ENGINEER DESIGNED REPLACEMENT t4 rl k 3 4 ' Q I O IJ OUT -OF -SERVICE SEPTIC SYSTEM A<r DESTRUCTION I< INSTALLATION WILLS"`ERVE: RESIDENCE ❑ COMMERCIAL �er ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ! SP J1 0-Ir.J7 NUMBER OF EMPLOYEES: i TERNATIVE SEPTIC TANK TYPE/MFG�j CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS ft DEPTH ft DISTANCE TO NEAREST: WELL/7�'7 T� 1 ft FOUNDATION /T ft PROPERTY LINE � /''L ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) DEPARTMENT USE ONLY Application Accepted By <�� ' Date 3 o0a Area 3 �C� Employee ID# Final Inspection By Date ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS on -re, a,Y, ,'er 11, 1�Zr:,oc�� n S Sf�W' dor rPsi<_.'IFh�F. C17S ,, n `�� 6F ori he< ruoYv� C X,��I�� i�>71c 0 1� PSfro�P L ,��s Imes' 4,z, ie e�L41I17C:`on PE SC Code INFO Lala ils 42-01 4/14/18 Received By LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft '�ODI Date •2�.2 DISTANCE TO NEAREST WELL ft FOUNDATION /0/4 ft PROPERTY LINE l ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft 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 c 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. MI UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 %% DATE SIGNEDTITLE DEPARTMENT USE ONLY Application Accepted By <�� ' Date 3 o0a Area 3 �C� Employee ID# Final Inspection By Date ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS on -re, a,Y, ,'er 11, 1�Zr:,oc�� n S Sf�W' dor rPsi<_.'IFh�F. C17S ,, n `�� 6F ori he< ruoYv� C X,��I�� i�>71c 0 1� PSfro�P L ,��s Imes' 4,z, ie e�L41I17C:`on PE SC Code INFO Lala ils 42-01 4/14/18 Received By heck#t Cash p Amount Remitted .aa Date •2�.2 Permitl Service Request # S2oo��-I Invoice # Permit ID# ONSITE WASTEWATER TRTMNT SYSTEM PERMIT T