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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-KEFUNDABLE PERMIT t:ALL ZU9 D3-/O'J/ FOR INSPECTIUNS tXPIIKtb T T tAK HKUM IJAIt 155UI JOB ADDRESS J H '� a ) ' ✓ CITY/ZIP 5 ��:/ k- �Y7 CROSS STREET V I�� /'�, APIN V !7 ./ DO / PARCEL SIZE 'fit] b 111 L OWNER NAME Sl,l S �L L% Q cgiQ / (--LR.�� P-1 O C1t� - PHONE ZLZI - V3-/ - S-6 OWNER ADDRESS ^�clti/-a v, rr 1 CITY/STATE/ZI ❑ L� CONTRACTOR SC -o L7 1( L, -J / / IPP / J e -a () I�,y�- Li 6jaD .ONE ! ! (!rJ I V,Jt�� CONTRACTOR ADDRESS �v l� F) JC -� 6 1 CITY/STATEIZIP KJQi �I 'AI ^r 14-6,1L (� p ! -6 i'L / LICENSE C-42 C-36 OTHER ` A / [ NUMBER G[o 8z�,y EXPIRATON DATE 764 ^1l-� L� �J �-�/� [ _ WATER TABLE DEPTH: 70 M It GEOGRAPHICAL INFORMATION: Coordinates X Y F- 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 I COMMERCIAL I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ,,j K) ,Q SEPTIC TANK TYPE/MFG �' `'`L` CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ..t6. ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS # OF LINES 1❑ 1 LENGTH OF LINES S� r ft ✓✓✓��\ DISTANCE TO NEAREST WELL / S�% ft FOUNDATION ft PROPERTY LINE ft ❑ FILTERBED WIDTH ft LENGTH ft DEPTH / ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH It LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER I WIDTH 3 It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE u 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. SIGNED :�M /DV TITLE 1(-- Wt C DATE / / 5 -- Application Accepted 5 -- - - DateI Area I Employee ID# 1.J IF t Final Inspection By /� _ ` Date SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS E din SVS'-ervl- GYIs1-In5 Dh?S to 1e Al 1/1. -rlP/ M4 vJP S PE SC Received Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO B Cash Remitted Re �al� Is 3o0 42-01 - ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4114/18 IIA�VT1U IV