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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 p CALL 209 953-7697 FOR INSPECTIONS � }�(Z-#./�,EXPIRES 1_y YEAR FROM DATE ISSUED JOB ADDRESS Z(p Sf 4-- � y J r��l N �(� b• CITY/ZIP -`, 6 L 0 CROSS STREET WA-L NV-T- GrP-OVC APN OC 1— 0440 - 1, PARCEL SIZE_'r•CQ� OWNER NAME L.VZ r"r�f -1p, 9-J ID�'I V'"y 6Z PHONE ��_ 1T�' •� G OWNER ADDRESS ZCSD O �� S.T. CITY/STATE/ZIP S-F-V'r CONTRACTOR L•iV C o Pvw- yV��II fRa�.1rNEN PHONE 3&11- 0315 CONTRACTOR ADDRESS 4L)-1 W O/`� D 1 CRY/STATE/ZIP Lot t C-A % A�4o LICENSE _I; C-42 11, C-36 OTHER C e& NUMBER 2-(T' EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # I BUILDING 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 11 COMMERCIAL Ll 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 It ❑ 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 PROPERTY LINE It ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION It 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 It 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. MINIMUM ji HOUR ADVANCE NOTICE E RED FOR INSPECTIONS-PLEASE CALL(209)953-769 SIGNED TITLE PQOJ YYtb(L• DATE IF III FA1l �o 0�0 c J DEPARTMENT USE ONLY Application Accepted J L--L� Date R1,2 Q b J Area t (I C Employee ID# Final Inspection By Date SPECIAL PERMIT-Approved by Character of Soi[,W Depth of 3 Flt: Pit/Sump Soil Character, COMMENTS o�0-�Lr O/1 /�I,L �j•rj -M i yt(�t�• A- PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# Code INFO ash Remitted Service Re uest# Li s-0 1 S 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18