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0NSITE 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 ADDRESS a✓ CRY/ZIP U J�L�w/ n CROSS STREET r [��1 W d r- . APN ` • - PARCEL SIZE o• 4 9 0 OWNER NAME PHONE r OWNER ADDRESS `-•�+ I I yJ� CRY/STATE21P 4 /�� yJ{ ^J CONTRACTOR V /ae/#14 PHONE O / Ae —/'✓%)� CONTRACTOR ADDRESS Pb "�F S�+y G7 )/CITY/STATE/ZIP (, �J p Q LICENSE �C-42 ❑-C-36 OTHER NUMBER �5"0/tr EXPIRATION DATE [ I �/+ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: _ NEW INSTALLATION _ REPAIR/ADDITION _. ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM - DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: p NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG (,0 . L�/ai��/§ CAPACITY /CMG y gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG ,v CAPACITY gal #OF COMPARTMENTS_ DISTANCE TO NEAREST: WELL la'MM/ Y ft FOUNDATION ft PROPERTY LINE 01 J ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT �j❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES 0 LEACHING CHAMBERS / #OF LINES ^^J LENGTH OF LINES • ft DISTANCE To NEAREST WELL It P Caws FOUNDATION O ' 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 It 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 R LENGTH ft DEPTH ft DISTANCE TO NEA ST WELL ft FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER E WIDTH /f ft DEPTH a'S I ft (((\\\ DISTANCE TO NEAREST WELL Oi�ft FOUNDATION 1?8 ft PROPERTYLINE Z ft 1 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 48 WUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 2 09 99 5/3-7r697 SIGNED TITLE DATE L -4- NJ �O i ve6 N� T EP TMEN SE NLY Application Accepted Bl< at Area Employee ID# Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil to th of 3 Ft: Pit/Sump Soil Character: COMMENTS R 11E. PE SC Received Check#/ Amount Date Permit/ Invoice# PermitID# Q�ode INFO Qy Qash Repitted Service Re uest# v 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18