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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 ADDRESSy/�l/f (/�/O�f✓�i' ri(�[ �% CITY/ZIP G f! }' CROSS STREET `� T AP �� tt�y �\ PARCEL YIZE OWNER NAME �C(CA \/� \� PHONE OWNER ADDRESS ` ZSr CITY/STATE/ZIP ON C�5�n�_ p_ CONTRACTOR _)C�yn I\�`� LL`C`�� `�e1 ` CIL• PHONE �c)c\-S-\G�.\--�15n�� CONTRACTOR ADDRESS ;,/��aL e SSU CITY/STATE/ZIPS LICENSE ❑ L C-42 ❑ I C-36 OTHER NUMBER LA1(-Q l EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION L. REPAIR/ADDITION _ ENGINEER DI Y D I I REPLACEMENT I i OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES Ll LEACHING CHAMBERS ft PROPERTY LINE ft # OF LINES ft ft PROPERTY LINE DISTANCE TO NEAREST WELL ft ft FOUNDATION DEPTH ❑ FILTER BED WIDTH ft LENGTH ft ft PROPERTY LINE ft DEPTH DISTANCE TO NEAREST WELL ft ft FOUNDATION ❑ MOUNDED WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SUMPS WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SEEPAGE PITS NUMBER WIDTH ft DISTANCE TO NEAREST WWW1 ft FOUNDATION ft LENGTH OF LINES ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED T APPLICATION AND HE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, E LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. /IIYIIIIVIYI -ru IIVVI\ VY/'7IY{,G IYIJ I IIrL I\L VII\GI./ rVR IIYJr CV II'LL/u/A�.7JJ-nn/ V.7/ SIGNED TITLE \i\(-- DATE DEPARTME AR Application Accepted By JU&WF Date Final Inspection By Date 1 O Area (, Employee ID# •� ❑ SPECIAL PERMIT -Approved by PE SC Received Check# Amount Permit/ Code INFO By emitted Date Service Request # Invoice # Permit ID# 2� � 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 H d d