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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 L.RLL (LU,9) `Jb.f-/O`.I/ FUM INSNLGI TUNS CAI'IKtJ I TtAK I-KUIVI LAIC IJJUtI JOB ADDRESS (J+ yUU� �UCr�� _CITY(//ZIPS/i/ CROSS STREET I/ /r�7�>�!,J�:/4ej t Flo `�Gr�61C(fl LEACH LINES 7 APN 007- / 00 ^ /8 PARCEL SIZE L O OWNER NAME St 'je 0 `cn L1 0 PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR eylf 41 �]l dal4;1 a ' C /�j� PHONE "-k'? �c�"' C� CONTRACTOR ADDRESS / i�� r7uY/ -1I`� I✓r- CITY/STATE/ZIP cS*C"�19. LICENSE ❑❑IYC-42 ❑CIC -36 OTHER NUMBER S yS EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM I I DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL 1 ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 / NUMBER OF EMPLOYEES: ❑ ❑ ❑ SEPTIC TANK GREASE TRAP LIFT STATION TYPE/MFG �X' TI h�1 �CeaCIt�2 TYPE/MFG DISTANCE TO NEAREST: WELL ft SIZE TYPE OF PUMP CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS FOUNDATION ft PROPERTY LINE ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft Invoice # LEACH LINES ,LEACHING CHAMBERS % #OF LINES I I LENGTH OF LINES yL / ft 0 00 ) /1_ � (J S / DISTANCE TO NEAREST WELL ft FOUNDATION 0 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 ❑ 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 SEEPAGE PITS DISTANCE TO NEAREST WELL ft FOUNDATION ft PROP,rE�RTY LINE NUMBER C9 WIDTH a�� ft DEPTHy S ft ft DISTANCE TO NEAREST WELL /Sb ft FOUNDATION CUi U ft PROPERTY LINE S 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. IVIIIYIIV/UIVI 1F0 nLFLjr[ I tLJVH/YIiC YV IIL.0 ![C U1r%E;L/ I-Vrx nvJrLV 11w1V 7 ' �LLLGMJC %,I -IL -L- LVJ JJJ-IVal SIGNED TITLE _,d/h-C/Co�i� DATE ( —2 / DEPARTMENT SE ONLY /+ Z Application Accepted By Date 2 Z- Area 7 7 Employee ID# CTOf�IA'/ �/z Final Inspection By �>' Date ❑ SPECIAL P RMI - Approved by Character of Soil to Depth of 3 Ft: A,, Pit/Sump Soil Character: !( -V'-Q COMMENTS PE Code SC INFO Received By Check#/ Cash Amount Dat Permit/ Remitted Service Request # Invoice # Permit ID# 0 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 n