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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 ADDRESSy.�� ( 7�j7V CITY/ZIP CROSS STREET TjftblSN( APN 00 If 'y Z PARCEL SIZE `•�J� p OWNER NAMET,, A PHONE OWNER ADDRESS7,3,R& k EC-: t L- CITY/STATE/ZIP Ard L4 f'o CONTRACTOR IiS /jC(�f� �C� ��t PHONE CONTRACTOR ADDRESS L_ x 41 O CITY/STATE/ZIP LICENSE OFIC-42 111.!C-36.'C-36 OTHER NUMBER G ] Ajj5 q EXPIRATION DATE WATER TABLE DEPTH:ad — 1 S ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# D LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION !1 REPAIR/ADDITION U ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I] DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL CI OTHER CI NUMBER OF LIVING UNITS: ' NUMBER OF BEDROOMS: _ J NUMBER OF EMPLOYEES: PTIC TANK TYPE/MFG �d-L CAPACITY !a.a� gal #OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL, It FOUNDATION 31ft PROPERTY LINE r ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TY.PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS #OF LINES_3 LENGTH OF LINES S- ft DISTANCE TO NEAREST WELL _ ��s]t ft FOUNDATION-41 ft PROPERTY LINE 3ft ❑ FILTER BED WIDTH ft LENGTH It 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 It ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER ., ) WIDTH ={C}It ft DEPTH o7S t ft DISTANCE TO NEAREST WELL__L„4�� It FOUNDATION �� ft PROPERTY LINE J ft 1 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. MINIMUM 48 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)/953-7697 SIGNED TITLE ` 1�tGt7 DATE /g 1 T O IN N E T � N DEPARTMENT S ONLY Application Accepted Date / Area Employee ID#� Final Inspection By Date I 6 I SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ff.. Pit/Sump Soil Character: COMMENTST(z 0 (16016f�c PE SC Received Check Amount Date Permit/ Invoice# Permit ID# Code INFO B ash Remitted Service Request# {I { 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18