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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 ADDRESS l K 7,AW CITY/ZIP LZ It ee J J �b v CROSS STREET / 1��/r, /Yl /O APN 7id4 V ` ()70 l/ PARCEL SIZE e b ME p / PHONE OWNER NA2-/C�Q( OWNER ADDRESS / 7 A CITY/STATE/ZIP l anlCLa / dn CONTRACTOR \�Q /✓ GiStL� W as/e PHONE CONTRACTOR ADDRESS ✓ Y,2,9 e /I Q / ! CITY/STATE/ZIP LICENSE 70-42 DI IC-36 OTHER NUMBER EXPIRATION DATE J r� WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION#, TYPE OF WORK: p NEW INSTALLATION V REPAIR/ADDITION (I ENGINEER DESIGNED/ALTERNATIVE I I REPLACEMENT CI OUT-OF-SERVICE SEPTIC SYSTEM U DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY 1,,Z gal #OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) - -------- - e r � ❑ LEACH LINES t/ LEACHING CHAMBERS_' (/� "FEINES 4GTH OF LINES U 0 ft DISTANCE TO NEAREST WELL ft r~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 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 UQUa ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 9'573-7697Q SIGNED TITLE / T/1uts,P/L ! DATE / — 16-4- Aiuh T U T DEPARTMENTIISE ONL Y Application Accepted By Date_ Area {[lEmployee ID# Final Inspection By Date ElSPE IAL PER -Approved by Character of Soil to De th of 3 Ft: Pit/ ump Soil Character: COMMENTS awo PE SC Received (Check U/ Amount Date Permit/ Invoice# Permit ID# Code INFO B V Remitted Service Request# 5C-0 I� 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4114/16