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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 /� EXPIR �ES 1 YEAR FROM DATE ISSUED JOB ADDRESS ` i��' Iry 7 1 C--3 CITY/ZIP ftc�7�y LVAjJ� CROSS STREET V6 O I I D'j Rd APN PARCEL SIZE v o d OWNER NAME P�^,�^Gi �F`0 �O� PHONE_Slo II /� '—16' �[n O I , n OWNER ADDRESS CITYISTATE/gZ�IP /--e_y C!:P 754.:7 .:7I N CONTRACTOR I �['G �, ^ �+��' PHONE CONTRACTOR ADDRESS CITY/STATE/ZIPr�ti}�c LICENSE ❑CiC-42 ❑CIC-36 OTHER_} NUMBER EXPIRATION DATE )Oao WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# 0 LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE L- ❑ REPLACEMENT LI OUT-OF-SERVICE SEPTIC SYSTEM CI DESTRUCTION INSTALLATION WILL SERVE: &4ESIDENCE ❑ COMMERCIAL ❑ OTHER UMBER OF LIVING UNITS: �1i NUMBER OF BEDROOMS: � ^► NUMBER OF EMPLOYEES: we"SEPTIC TANK TYPE/MFG A-L CAPACITY gal #OF COMPARTMENTS�� ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL S.1 ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROCkERR2T LINE! ft FILTER BED WIDTH r's' ft LENGTHAba.1 ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION /� ft PROPERTY 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 P0I4DS 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. MINIMUU 0 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (2091 953-716997 Z SIGNED / TITLE — ffer.�jSt DATE ` I 17* QU/A C T D Mq� ry T _ ROA EP-A RTMENT US NLY Application Accepted By Date Area S Employee ID# Final Inspection By V' Date (0 SP CIAL PERMIT-Approved by,, Character of Soil to Depth of 3 t: Pi Sump Soil haracter: I / COM,,}}M--ENTS U s- - 4 i m l j 9 Ft mi tyi i I PE SC Received Check#/ Amount Permit/ Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# 5S4 4 "19.22v `3\R v 42-01 Cell'L ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18