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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 L;/4LL (ZU,9) &OJ -10.91 FOR INSPECTIONS tXPIRE5 "I TEAK FKOM UAI L ISSUtl JOB ADDRESS S'O C ITYIIZZIP 2 �I%YI 0 ( % CROSS STREET Pe /�I �� I L -V cel/ APN D O� /v O^ J PARCEL SIZE , " Z OWNER NAME �`SG1 PHONE OWNER ADDRESS CITY/STATE/ZIP Lf(�- 7 �7 CONTRACTOR C ( �� U0 ////r �F /h/ PHONE ^ (?,y�l��{jr��0y CONTRACTOR ADDRESS '/ (P� N ��^ P"', CITY/STATE/ZIP LICENSE [h -42 Eli ;C-36 OTHER NUMBER wEXPIRATION DATE WATER TABLE DEPTH: SC INFOSh ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # Date BUILDING PERMIT # O 2 LAND USE APPLICATION # TYPE OF WORK: X7NEW INSTALLATION C REPAIR/ADDITION C._ ENGINEER DESIGNED /ALTERNATIVE // REPLACEMENT I ! OUT -OF -SERVICE SEPTIC SYSTEM L DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL OTHER NUMBER OF LIVING UNITS: NU BER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG C CAPACITY � gal # OF COMPARTMENTS a ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS,+ DISTANCE TO NEAREST: p WELL / ` ft FOUNDATION / ft PROPERTY LINE 00 I� ft / ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) XLEACH LINES / U LEACHING CHAMBERS # OF LINES LENGTH OF LINES SS ft DISTANCE TO NEAREST WELL ft FOUNDATION— ft PROPERTY LINE /IDO 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 . ❑ 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 NEA ST WELL ft FOUNDATION ft PROPERTY LINE ft 1 SEEPAGE PITS NUMBER ' e� WIDTH "Ca Ir ft DEPTH (.,5 I ft DISTANCE TO NEAREST WELL iso ft FOUNDATION O ft PROPERTY LINE �0 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. IYI111111YIVIY) YO "V VR MU VN/YIrG V I Ili I= RC VIIx CL/ rVrt IIYJr"Gl' 1I V//YJ - rLCHJC I.iHLL LVy yJJ-/ U.7/ SIGNED '�dI/Y TITLE 6 `i /A.— DATE F DEPARTMENT U E O LY Application Accepted By Date 29 22 Area Employee ID# Final Inspection By k Date Z ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS /i%2i✓ S'T tivr ,��Ir�ti PE Code SC INFOSh Received Check#/ Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 2i // 2 ' 2L 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18