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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 C EXPIRES 1 YEAR FROM BATE ISSUED ,7 JOB ADDRESS �O L S� � CITY/ZIP 7w�� 1F7 � ✓ CROSS STREET GGA</�dl��%L� APN j /jJ— ©go ill PARCEL SIZE T a OWNER NAME ` N�"'–Y 7-/&/$ SPHONE U OWNER ADDRESS 2UG U Sr CITY/STATE/ZIP CONTRACTOR �L G, /"LyPHONE CONTRACTOR ADDRESS z 3� ` CITY/STATE/ZIP LICENSE ❑CiC-42 �irIC-36 OTHER--------- _ NUMBER Qf�B�ct EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y El ERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIG ED/ALTERNATIVE REPLACEMENT 11 OUT-OF-SERVICE SEPTIC SYSTEM IJ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: E3 SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ® GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft E& LIFT STATION SIZE TYPE OF PUMP Q PKG TX PLANT Q SAND OIL SEPARATOR(ENCLOSED SYSTEM) El LEACH LINES ILEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft EI FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE Y�" 1 ft El MOUNDED WIDTH ft LENGTH ft DEPTH �[�� ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN kA �/�� ft E! SUMPS WIDTH ft LENGTH ft DEPTH / �� 7 �fn._ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERT$J�I�E U ft Q DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH EN QVIN C ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PRO� NTAL ft EI SEEPAGE PITS NUMBER WIDTH ft DEPTH T 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. N9N11 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEA SE CALL (209) 95,3-7697 SIGNED TITL'( DATEZZ�j� (L L PARTMENT LJSE ONLY /f Application Accepted y Date Area (/ Employee ID# Final Inspection By 0 1 Date jj/IM� ❑ SPE AL PERMIT-Approved by Character of Soil t epth of 3 Ft: Pi Sump Soil Character: COMMENTS L! ± moo PE Sc Received hec Amount Permit/ Code INFO B Cash emitted Date Service Request# Invoice# Permit ID# oZ � '22•t°1 �-� 0 SS 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/16