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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 GALL (2179) 953-7697 FOR INSPECTIONS ,�LXPIRES I YEAR FROM DATE ISSU JOB ADDRESS 3�^�l13 C. C&U"AN A • CITY/ZIP ♦-C ` MP0 115-240 CROSS STREET �V N( C' E APN 0 0�+ - IWL �' PARCEL SIZE I. 0 OWNER NAME 10XLEN)Z G•DN'LALE-{ ANA -94A PHONE (9I(t) 8014. Ott)& E, OWNER ADDRESS 1 , t-piM ` CITY/STATE/ZIP CONTRACTOR LAVE: E O?(V- &" wJ iizay '►ESL- PHONE 3(C9 -03'1f CONTRACTOR ADDRESS 40 -1 w • D AY- ST • CITY/STATE/ZIP Lot> ( CA ` / q 5- 240 LICENSE C42 C-36 OTHER C t! V NUMBER Zi Sl E%PIRATION DATE 4 - 3o - z4 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y jC PERC TEST # BUILDING PERMIT # DISTANCE TO NEAREST LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE It DEPTH ft REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: _' RESIDENCE I COMMERCIAL E! 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 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 ft Date DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ FILTER BED WIDTH It LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It O MOUNDED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SUMPS WIDTH ft LENGTH ft DEPTH_ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH_ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH _ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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. MINIMUU41WWR E NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209) 953-7697 SIGNED TITLE P12 -0-J- lM &IZ • DATE L ` ?? wry Application Accepted ByDate AreaLI/ Employee ID# ZNT Final Inspection By'� Date ' ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE Code SC Received Chec / INFO By ash Amount Remitted Date Permit/ Invoice # Permit ID# Ser ice Re,,,l # aaa sa3 lsa 8 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18