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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 TYPE/MFG GAL (ZU9 953-7697 FOR INSPECTIONS LXPIRES 'I FROM UATE ISSUE JOB ADDRESS ' d L CITY/ZIP CYEAR n CROSS STREET , `� gal # OF COMPARTMENTS APN b) _jig as a PARCEL SIZE ,! O OWNER NAME 1C�7W� u� I � ft �/ PHONE '" } 1,S7OWNER ICCr ADDRESS ! l ,,F, 1Af&, /n d CITY/STATE/ZIP / 7S u CONTRACTOR_Dxv'� `/� �' !� PHONE � �1 ^�J `J�^ CONTRACTOR ADDRESS `' `Z / n CITY/STATEIZIP ft FOUNDATION ft PROPERTY LINE ft LICENSE ❑I.''C-42 011C-36 OTHER WIDTH ft LENGTH NUMBER / 17-�S5 EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # I BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: Li NEW INSTALLATION C REPAIR/ADDITION-�ENGINEER DESIGNED /ALTERNATIVE I REPLACEMENT I I OUT -0F -SERVICE SEPTIC SYSTEM ter. DESTRUCTION i4jil< INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY Check#/ Ca.%h gal # OF COMPARTMENTS Date ❑ GREASE TRAP TYPE/MFG CAPACITY a) gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION " oU 5-11-S1? ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES Ll LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION 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 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 1 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. Q1N1Mb1Z40 UR ADVANCE NOTICE REQUIRED FOR INSP CTIO -- PLEASE CALL(209) 953-7697 SIGNED TITLE f `S �"l ) DATE _l ^4` 2 DEPARTMENT USE ONLY p /� Application Accepted By. �-� /�-� Date -Cl) O� .�� Area 7 Employee ID# PJt Final Inspection Date J0-,beA�22- ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS 1__�Ivv -D d F have PE Code SC INFO— Received y Check#/ Ca.%h Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# a) 076- 1s 'g -'z " oU 5-11-S1? 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18