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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 r� EXPIRESU1 YEAR -/FROM DATE ISSUED JOB ADDRESS CITY/ZIP CROSS STREET ^ `APNIV(-i Vr�C PAZ rPARCEL SIZE I �l� C OWNER NAME M e r'.u,(� ``hY�:n P PHONE IC2% f"'-\- C / - )L `�yi OWNER ADDRESS \l J �� F�V� CITY/STATE/ZIP��, 1 J 1 CONTRACTORSRI.Vj PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE 110C-42 11CIC-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: I ft GEOGRAPHICAL INFORMATION: Coordinates X' oJZ331->,y Y 1J\.H� 2�Sj� ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION J ENGINEER DESIGNED /ALTERNATIVE u REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: 11 RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: 19 Application SEPTIC TANK 11 TYPE/MFG CAPACITY t UU gal # OF COMPARTMENTS Li` /U ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PK�G TX PLANT L3 SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES 9 LEACHING CHAMBERS I hl I,r�l �# OF LINES �r\ LENGTH OF LINES A� DISTANCE TO NEAREST WELL `S V � �-® ft FOUNDATION 20 ft PROPERTY LINE ? ft ❑ 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 RY SUMPS WIDTH ft LENGTH \ h ft DEPTH ft DISTANCE TO NEAREST WELL 1 7�ft FOUNDATION 10 ft PROPERTY LINE 2 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 95- 9l 7 SIGNED /3-7 e- �, ,(- DATE C 1 J a -z- TITLE V lamU w 7 z - Application Accepted Final Inspection By_ Character of Soil to D COMMENTS N r DEPARTMENT USE ONLY '&S Date Area Employee ID#_ Date 2 ❑ SPECIAL PERMIT -Approved by of Ft; Pit/Sump Soil Character: PE SC Received heck# Code INFO B Amount Remitted Date Permit/ Invoice # Permit ID# Service Request # Li` /U l 2 `7 f I 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18