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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 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 17 O ] w IID#J SOS TEN CITY/ZIP q9-304 � CROSS STREET /M dUA/Tr iA-f !'1UySGy APN Z0I"JTO'� I PARCEL SIZE 3.-13 Ac / � ' p OWNER NAME GA-GA�ti✓GCP SI nlGl-F- PHONE (SI OJn�p OWNER ADDRESS 41-7 �'V . S&IAII T/ r 7zAA/C0S AVc . CITY/STATE/ZIP? fM0VN'-�7MC PJ d"SE,CA /S37 �n CONTRACTOR L.l VC d�X- lSEDE►.11./IRon/Vi'IFJ�Iq(- PHONE 3�0�J O3 f CONTRACTOR ADDRESS 40-7 W • UAIC' ST. CITY/STATE/ZIP (^pDI CA 9s1-4c) LICENSE C-42 : C-36 OTHER C 15 U NUMBER Z 157 1 ERPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: .... RESIDENCE I COMMERCIAL L OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE It —7 �( ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) U _______ ____................--_---____ ------- ---- -- _.....---..-..--_.. ( St �- ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL If FOUNDATION It PROPERTY LINE It ❑ SUMPS WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ' It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It 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. UM HOUR ADWINCENTI E REQUIRED FOR INSPECTIONS-PLEASE CALL2 SIGNED TITLE PILO-JI DATE Z`ZS'Z( PAYMENT RECEIVED FEB 2 4 2021 AN JOAQUIN COUNTY ENVIRONMENTAL EALTH DEPARTMENT t 0 r // DEPARTMENT USE ONLY j\ Application Accepted BI ��v� Date Area S Employee ID# Dile Final Inspection By Date ��z/ L SPECIAL PERMIT-Approved by Character of Soil to QiiptGf Ft: Pit/Sump Soil Character: COMMENTS PE SC Receiv Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO ash Remitted Service Reauest# �aaa sa3 0 1st 1 3 3 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18