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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 G CALL (209 953-7697FOR INSPECTIONS EXPIRRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 13-7 � G- V1 C vl� CITY21P L-01>1 9T2--A0 CROSS STREET u�J A�C'te- TV-"J E7 APN OS'3- 030` 1 ^PARCEL SIZE 6). I p OWNER NAME I (�{66� ��-� PHONE OWNER ADDRESS 'sr,1�L CITY/STATE/ZIP H �� ✓CJ��I CONTRACTOR G'Ulej-�e7& 1 t -7 G L. PHONE 7 /-o3l 5- t, CONTRACTOR ADDRESS -T'6 (/y OA K ST t- CITY/STATEJZIP L-6-r> ( CA IT 7- o LICENSE C-42 11 ;C-36 OTHER C E CS NUMBER -I J I EXPIRATION DATE -4-3L -LZ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # LI FBUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ,. ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: _' RESIDENCE J COMMERCIAL - OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ 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 ❑ 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 It FOUNDATION ft PROPERTY LINE ft ❑ 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 ft ❑ SUMPS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft 1 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. MINIM E NOTICE RE IRED FOR INSPECTIONS-PLEASE AL -7 7 SIGNED TITLE I�IIZ�J• Mb'� DATE F71 1 .04 y?�20 c p Fiy q�N�y _�� DEPARTMENT USE ONLY Application Accepted �/� L Date I ice' Area Employee ID# Final Inspection By Date Z i7 SPECIAL PERMIT-Approved by Character of Soil to epthnof 3 Ft: Pit/Sump Soil Characte COMMENTS _ H1 OPEC ►�A � S nt^'�l�ir1L� rA PE SC Received hec Amount Date Permit/ Invoice# Permit ID# Code INFO B sh Remitted Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18