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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 f �Q d��/LS CITY/ZIP VJ^-) 9 5-34 LA CROSS STREET / of Phy APN ��S -/ PAARCELSIZE OWNER NAME AqA.)�` ") PHONE OWNER ADDRESS 1703 C�IIp��Q� Ave n CITY/STATE/ZIP /21QD1:57" CONTRACTOR h ookpg , J V'�`�' --si-'yyn PHONE tir 7 r�� 3 r n CONTRACTOR ADDRESS �/ �/Q {^��N�"i WCITY/STATE/ZIP LICENSE CIC-42 ELIC-36 OTHER / 1 NUMBER r EXPIRATION DATE [][]C-42 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: II NEW INSTALLATION ❑ REPAIR/ADDITION l7 ENGINEER DESIGNED/ALTERNATIVE 09 REPLACEMENT CI OUT-OF-SERVICE SEPTIC SYSTEM X DESTRUCTION f-:14)< INSTALLATION WILL SERVE: 8 RESIDENCE ❑ COMMERCIAL E OTHER NUMBER OF LIVING UNITS: � NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: '® SEPTIC TANK TYPE/MFG I L A,t-'z/t CAPACITY a v gal #OF COMPARTMENTS 2 ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL �y� ft FOUNDATION p ft PROPERTY LINE ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES 1P LEACHING CHAMBERS Nr1�,/'/J #OF LINES�_ LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE a 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 ft PROPERTY LINE ft SUMPS WIDTH ft LENGTH I I1 ft DEPTH I Z ft DISTANCE TO NEAREST WELL 1.51) ft FOUNDATION 10 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. MINIMUMA8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED� , TITLE �j/J 1/" J/ DATE 3- M N 0 Q � T M N T E I D&PARTMENT U E ONLY ftVatel Application Accepted B - `/ Date Lb _ Area Employee ID# YC�t Y7 Final Inspection By dd Date 7i 20V SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sum Soil CS,atter: COMMENTS 1C e e&0-0 }CiP - yJ S s ev►^ ��r Pr;,+�r�c� )'Ps I/ClpNce,LLO(d hitk 'fo b—f�o�( o f o L.L 21- i - PE SC Received heck Amount Date Permit/ Invoice# Permit ID# Code INFO B ash Remitted Service Request# ya ►os 3� SR 00 1 1 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18