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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 KION-REFUNDABLE PERMIT CALL (209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �Z Z �`� !N/�(_ CITY/ZIP v ✓J� .f'L -i CROSS STREET �� /syr APN �a,3 7 PARCEL SIZE i / 0 d OWNER NAMEinn, / ( n, 7l. PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR PHONE s� p/^ � �/- CONTRACTOR ADDRESS //V • n�l�• L� /� CITY/STATE/ZIP LICENSE 111IC-42 EIEC-36 OTHER NUMBER EXPIRATION DATE_ l//2J 5 WATER TABLE DEPTH: VO O ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# - WP30 0 LAND USE APPLICATION# TYPE OF WORK: jr NEW INSTALLATION O REPAIR/ADDITION LI ENGINEER DESIGNED/ALTERNATIVE 1..1 REPLACEMENT CI OUT-OF-SERVICE SEPTIC SYSTEM 1-1 DESTRUCTION INSTALLATION WILL SERVE: It RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG _ GCAPACITY al #OF COMPARTMENTS -77 _ ® GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL_2 d o, ft FOUNDATION ft PROPERTY LINE �_G47 o ft Ca LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES SJR ft DISTANCE TO NEAREST WELL�OO _ ft FOUNDATION /00 ft PROPERTY LINE �7J 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 CY 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 N A ST WELL ft FOUNDATION ft PROPERTY LINE ft ® SEEPAGE PITS NUMBER WIDTH__- yZft DEPTH ft DISTANCE TON AR ST WELL3�O ft FOUNDATION 2 '2p• ft PROPERTY LINE _ -200 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 UR ADVANCE NOTICE REQUIRED? FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE DATE l� NTL— ENVIRON1 AE14TIL ..D PAR TMENT o N Y �j�[l[ �/� Application Accepted By Date l Area 1� Employee ID#Afhkew f) Final Inspection By_/ /1A IQ,� Date El SPECIAL PERMIT-Approved by Character of Soil to Dep of f 3 Ft: �� r . Pit/Sump S it Character: COMMENTS PE 5C Received Check#/ Amount Permit/ Code INFO Bas Remitted Date Service Request# Invoice# Permit ID# t t t 5 0� -101 X1--1 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18