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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)488-3420 NON-REFUNDABLE PERMIT CALL(2009)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS -1 07-1 tz&2•1 C'1z FN CRY/ZIP L-INDEN qV'-7-3(p CROSS STREET C Lt m�.N T S APN D ��1-I 0 0 PARCEL SIZE 1 D OWNER NAME Y�I LJG vi 1 PHONE 69 O O 1 Q p q y OWNER ADDRESS S1 1 1 E• LI J G O^r- t> • CITY/STATElZIP CONTRACTOR LI J t O^K PHONE-361-031T CONTRACTOR ADDRESS 4011 wi• O^&IC S—T• CITY/STATE/ZIP L-0'01, C-A q J Z44Q -ZWATLICENSE LiC-42 0 C3C 8 OTHER (FI'T NUMBER �-1 1 EXPIRATION DATE T^3 Z-2- WATER ER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y �C PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I:, ENGINEER DESIGNED/ALTERNATIVE .J REPLACEMENT ::: OUT-OF-SERVICE SEPTIC SYSTEM i DESTRUCTION INSTALLATION WILL SERVE: _ RESIDENCE D 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 It 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 ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH R DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It ❑ SUMPS WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH It LENGTH It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It 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. MINIMUM 40HOUR QUANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CAL953-769 SIGNED TITLE PRO eA C-A-• DATE PAYMENT RECEIVED AUG 2 3 2021 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT l DEPARTMENTSE' NLY Application Accept By r L- Date Area �l Employee ID# Final Inspection By Date('L�k lZ ISPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS -P ry-4-4_ Q-A>,yIr, -CSS \l. Ok, PE SC Receiv Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO a Remitted Service Request# LIda3 Sa3 Isa 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18