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t 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 CITY/ZIP Q -I CROSS STREET -/ O APNPARCEL SIZE C�f�/�� OWNER NAME LO�p Y�j, PHONE OWNER ADDRESS �+ �' r CITY/STATE/ZIP �Cf/' L� C '7�J CONTRACTOR ►f7 41l L��`�- �/J /' PHONE. do'I J�Y, ' _J/��Ci' JC��^'� �y CONTRACTOR ADDRESS / 4e 6 �� o ��C /�/ CITYISTATE/ZIP �I�CX/fT1'N� l• !��%�/ LICENSE El N-42 ❑=C-36 OTHER NUMBER /f EXPIRATION DATE qI -/"I WATER TABLE DEPTH: e '70 It GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDINGPERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION F. ENGINEER DESIGNED/ALTERNATIVE L REPLACEMENT _ OUT-OF-SERVICE SEPTIC SYSTEM _ DESTRUCTION INSTALLATION WILL SERVE:------ ERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: �^I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: 13 SEPTIC TANK TYPE/MFG 61CjSbM/) CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG J 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 C LEACHING CHAMBERS #OF LINES LENGTH OF LINES V0 ft 111111 DISTANCE TO NEAREST WELL ft FOUNDATION _ft PROPERTY LINE It ❑ FILTERSED 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 PROPERTY LINE ft ❑ SUMPS WIDTH It LENGTH It DEPTH It DISTANCE To NEAREST WELL ft FOUNDATION R PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It DISTANCE TO N EST WELL ft FOU ATIO_N ft PROPERTYLINE ft SEEPAGE PITS NUMBER WIDTH , ` ft DEPTH CP`5 -' ft DISTANCE To NEAREST WELLzS'0 r ft FOUNDATION O ft PROPERTY LINE �(..i 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 f SIGNED TITLE L./�sf/r'�'�✓ DATE 2 &9,9 cNov r 323 2021 I Rai EV E oUN17 NTAL ARTIyENT r! DEPARTMENT USE ONLY Application Accepted By n �`— Date Area C� Employee ID# 1)*4 Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil to De�llfi of Pit/Sump Soil Character: COMMENTS Int-dine sten i"n s 'to irl. Alts dels o.4 j'), st i ;c� j h1 PE SC - Receive A Date Permit/ Invoice# PermitlD# Code INFO ash miffed S ice Request# :t 3 'f5 '0aJ 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4114/18