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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 GALL ZUY) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS O rderiek CITY/ZIP 1 e /t ❑ LEACHING CHAMBERS 1 CROSS STREET,�c� APN L -2 S,`- / J D— -3 2 PARCEL SIZE _2 Cz OWNER NAME P`` �%J !% Q (`7L 22 z E�% /,, S PHONE ��O �r?-2 17.2-- Q� ^�y /�/� OWNER ADDRESS _Z 7 4 , % r �� iJ� CITY/STATE/ZIP lei DISTANCE TO NEAREST WELL ft CONTRACTOR e S j PHONE O /n7} WIDTH ft LENGTH CONTRACTOR ADDRESS �p i / 9 CITY/STATE/ZIP zilez DISTANCE TO NEAREST WELL ft LICENSE1C-42 [10C-36 OTHER NUMBER 3�ffEXPIRATIONDATE ^�/ �2- WIDTH ft LENGTH It DEPTH ft WATER TABLE DEPTH: �rJ' ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION j ' . : I Cl REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE ❑ ❑ ❑ SEPTIC TANK GREASE TRAP LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL ft SIZE TYPE OF PUMP CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS FOUNDATION ft PROPERTY LINE ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) Amount Remitted LEACH LINES ❑ LEACHING CHAMBERS J/ # OF LINES LENGTH OF LINES t11 3, ft Permit ID# Ia DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE / ft ❑ FILTER BED 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 ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft 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 ft 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 48 HOUR.ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL _(209) 953-7697 SIGNED TITLE 6�'I✓A -el �a hDATE ; DEPARTMENT USE ONLY _ Application Accepted By Date 101.2-71d I Area S Employee ID#_ Final Inspection By M Date o ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: PitlSump Soil Character: COMMENTS i s I CSO' i P�a -I' r_�,XiAn4 11wes ►nP:J I)APS to hp. nL'a(_P(' tt✓1 hn �-trJ?r'�� OIC! hsCeG11 1INFC- PE Code SC INFO Received By he Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# Ia )1S" t300 )a.Z 00jLILIo 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18