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V1 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 A / i 7 CITY/ZIP CROSS STREET-f6Cl�- 4f / APN 1 0 l3 W S PARCEL SIZE OWNER NAME /�I f ��/ / C<vrrl1e PAL$(PHONE �✓ yC/?c �%% 47/,OWNER ADDRESS L] —CITY/STATE/ZIP i 4 -at, �+6-n CONTRACTOR /5 /G /1'%�ii%�L%IIAM rjtli/. !_ - PHONE -2-A Z CONTRACTOR ADDRESS �% �L az CITY/STATE/ZIP LICENSE ❑ C-42 ❑L]C-36 OTHER NUMBER / EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X ❑ PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION I1 REPLACEMENT INSTALLATION WILL SERVE: NUMBER OF LIVING UNITS: SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION LEACH LINES LAND USE APPLICATION # REPAIR/ADDITION OUT -OF -SERVICE SEPTIC SYSTEM ❑ COMMERCIAL NUMBER OF BEDROOMS: C Y ENGINEER DESIGNED /ALTERNATIVE DESTRUCTION ❑ OTHER NUMBER OF EMPLOYEES: TYPE/MFG CAPACITY -.6/200 _gal # OF COMPARTMENTS_ TYPE/MFG DISTANCE TO NEAREST: WELL ft CAPACITY ) FOUNDATION ! gal ft # OF COMPARTMENTS PROPERTY LINE ft SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACHING CHAMBERS DISTANCE TO NEAREST WELL ft # OF LINES FOUNDATION , ft ❑ FILTER BED WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ❑ MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SUMPS WIDTH ft LENGTH 13 1 LENGTH OF LINES y ft PROPERTY LINE S ,/ ft DEPTH ft PROPERTY ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION DISPOSAL PONDS WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION SEEPAGE PITS NUMBER -2 WIDTH 3 / DISTANCE To NEAREST WELL //�T� ft FOUNDATION�� ft PROPERTY LINE ? ft ft - —ft PROPERTY LINE J,(! DEPTH �'� L / �fw_ft ft PROPERTY LINE - j DEPTH HEd�,.1R INCO _ft PROPERTY LINE �EPgp%AC itr ft DEPTH 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. DATE DEPARTMENT US.E ONLY I qApplication Accepted By G� (/� Date -7cp;l a Area of Employee ID# _ Final Inspection By Y ([ M; S Date t3! %�, 12 1. ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS .SfCoXld U/0 DWC11;J%j Ti of Zl:f jAcYi-geAI r r �Gv�k .5 eis)- ,oP,f SS/vLS PE Code SC INFO Received By Che –Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# Lq,a1) 11`7 2 A?Ll 122.22 SK00 9`�5v g 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18