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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 SEPTIC TANK G^ALL (LUY) .90J -/0.91.90J-/0.91 FOR INSPECTIONS tXPIRES 'I YEAR FROM UATE ISSUE JOB ADDRESS [ao L( O 1 CROSS STREET Hwy w � � _ ^- I "1'' 90 CITY/ZIP � C -'t' t APN n? q5 C60 a 1 !q %foci r� 6't - 't -CROSS PARCEL SIZE OWNER NAME ��( J'b��7y ,/ ` J -LQ/� /^�rfj / PHONE OWNER ADDRESS 1 C� � Y J C�wd�L CITY/STATE/Z�IPfGrd Y,,yll ye -4 CONTRACTOR(ILLS +/J� /1�� O� �r• PHONE CONTRACTOR ADDRESS � A nv ! OS CITY/STATE/ZIP 1 1r I1nGA ✓$ q 33 Co LICENSE ❑ ❑C-42 ❑ ❑C-36 OTHER -tel NUMBER EXPIRATION DATE �oZ WATER TABLE DEPTH: / -0 ~ ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: Ci NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE .i REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS:-/CINUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS a la i s DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES ftDISTANCE ZER TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft BED WIDTH �� ft LENGTH `� y ft DEPTH !�S 1I ft DISTANCE TO NEAREST WELL (0-0 1 ft FOUNDATION 16, ft PROPERTY LINE b I ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft 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 A VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE DATE �1I T7 DEPARTMENT US ONLY 'r^ryT Application Accepted B —/� Z L Date q Area `� Employee ID# �l Final Inspection By Date ujo(��71 ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/bump Soil Character: COMMENTS C-, l zJj'Y)A 11 6611,P6 PE Code SC INFO Receive Chec By ash Amount Remitted Dat Permit/ Servic 5a guest # Invoice # Permit ID# a la i s 3cq 7to 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18