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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-KEFUNDABLE PERMIT JOB ADDRESS ( —7 CROSS STREET _ VI OWNER NAME N 953-7697 FOR INSPECTIONS rXPIRES 1 YEAR FROM UATE ISSUE CITY/ZIP APN / "( 3 2 y O 7 2 PARCEL SIZE 3— Z 1 PHONE /( l2 v OWNER ADDRESS � —f1SC'3CONTRACTOR PHONE CONTRACTOR ADDRESS ! / '� / �P��✓ CITY/STATE/ZIP LICENSE ❑I_ C-42 00C-36 OTHER !/ ) NUMBER—?j J �I�S EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATIO ,CIREPAIR/ADDITION C ENGINEER DESIGNED /ALTER/NATIVE A REPLACEMENT yr' L �aS1fa�❑ OUT -OF -SERVICE SEPTIC SYSTEM K DESTRUCTIONS iy INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL f eray ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Og4qAb�. t0 NUMBER OF EMPLOYEES: 0 SEPTIC TANK TYPE/MFG �C��e CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL 10D ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LI LEACHING CHAMBERS #OF LINES LENGTH OF LINES ck ft Invoice # DISTANCE TO NEAREST WELL ft FOLINDATION ft PROPERTY LINE ils ft FILTER BED WIDTH ti ft LENGTH I(� ft DEPTH ©e) J ft DISTANCE TO NEAREST WELL Z --% ft FOUNDATION -0- 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 ❑ 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 4/8 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED f/ /��- TITLE �J.v ��1C�f" DATE �/ Z 2- ,..7-� DEPARTMENT US ONLY "11M Application Accepted By — �4— jrZ_ Date v�� v?o� Area � Employee ID# Final Inspection By Date ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS 0j)CJ +QfM1'V7V'd �",��r RPolncewevli tc obtdc r-itilew, l -,t isii 1-- je cAandored, DooWe U Y) c/e a I l �)'es PE Code SC INFO Received By ck Amount Date Permit/ Remitted I Service -Re uest # Invoice # Permit ID# a)o ils 3)a 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18