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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-KEFUNDABLEPERMIT TYPE/MFG �O/1 C, GALL (LU'J),90J-/6y/ FOR INSPECTIONS tXPIRES 'I YEAR FROM DATECIISSSUEC JOB ADDRESS / 1'`/PI 4^� 2�P led. CITY/ ZIP , SA CROSS STREET �d/L✓Gj% 5/f e. er AP (/ I 110 I '�I/' PARCEL SIZE , OWNER NAME _ /�j/iS%/. WELL G' U PHONE 7e OWNERADDRESS /[ / ZA i�'/ I%- CITY/STATE/ZIP %✓O� GI �r SSG �� S�S CONTRACTOR ��J- �O/j S�U��/�L� PHONE WELL CONTRACTOR ADDRESS ��QQ S'� �t-nC�S �,J•�-� CITY/STATE/ZIP /27"r �l iSr;;dj (f*_ ff4il LICENSE ❑❑C-42 ❑❑C-36 OTHER 4- NUMBER Z/71,75' EXPIRATION DATE Z �z c�/ Z Z WATER TABLE DEPTH: / Q ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # d 10 1 :7.� LAND USE APPLICATION # TYPE OF WORK: iX NEW INSTALLATION i REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL /f ❑ OTHER % 1 IC141 NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: :L NUMBER OF EMPLOYEES: ® SEPTIC TANK TYPE/MFG �O/1 C, CAPACITY /-f0 G gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS Permit ID# DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE 4mee ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) N LEACH LINES D LEACHING CHAMBERS FOUNDATION DISTANCE TO NEAREST WELL FILTER BED WIDTH ft Permit ID# DISTANCE TO NEAREST WELL MOUNDED WIDTH ft DISTANCE TO NEAREST WELL SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL DISPOSAL PONDS WIDTH ft FOUNDATION DISTANCE TO NEAREST WELL SEEPAGE PITS NUMBER ft DISTANCE TO NEAREST WELL # OF LINES Z LENGTH OF LINES __<_-0 Z %9 \ ft FOUNDATION L s LENGTH Date Permit/ Service Request # ft Permit ID# ft FOUNDATION LENGTH ft ft FOUNDATION LENGTH ft ft FOUNDATION LENGTH ft ft FOUNDATION WIDTH ft FOUNDATION ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE O411 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. IVIIIVI/V/Vml 4o VH/VIiC IVV IIL'c I[C ulmE J r -VR IlvJrcis l IV/VJ - r-LCtiJC %.tir-r- I LVJ V00 - SIGNED TITLE Z,v^j O i�� ' DATE // 1�&� bEPARTMENTUSE ONLY Application Accepted By Date(Area — `%f Employee ID# Final Inspection ByWjiw'X4_ ` Date G jt( ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS vj k'ku ft ft ft ft ft ft ft ft ft ft ft ft PE Code SC INFO Received By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 42-01 C�9 j;)')j214qq'aU ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 T