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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 HERMIT GALLILUyI y53 -/6'J/ FOR INSPECTIONS tXPIRES l YEAR FROM DATE ISSUEI JOB ADDRESS Obi 0 1;tS )q(A /V rUA, CITY/ZIP 4//7, CROSS STREET %_//%} J , APN [/ �2 S' P-,,ARR�CEEL SIZE OWNER NAME `�2/1z,44�� /-�jj? V Permit ID# PHONE OWNER ADDRESS J 7, Zle4e-14 4 11 (?' ' CITY/STATE/ZIP DISTANCE TO NEAREST CONTRACTOR L / �� (J/Gy/i�� ��jG'!Y! j/7l J PHONE 6OSOJ7/ �+ G j65 CONTRACTOR ADDRESS 3�5 Cl-/ iiYTi�,LJ aL._ WIDTH CITY/STATE/ZIP ft DEPTH ft DISTANCE TO NEAREST LICENSE ❑DC -42 ❑/C-36 OTHER /lN � / n NUMBER 9033 EXPIRATION DATE ft PROPERTY LINE ft ❑ MOUNDED WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: L NEW INSTALLATION ❑ REPAIR/ADDITION I I ENGINEER DESIGNED /)ALTERNATIVE REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM k DESTRUCTION �Yl k INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP ft CAPACITY CAPACITY FOUNDATION ❑ PKG TX PLANT ❑ gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS Permit ID# # 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 ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEft ❑ SUMPS WIDTH ft LENGTH ft DEPTH =^121111ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH I/j:/" ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY L1f E 4Le ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH OAQ�/N ft DISTANCE TO NEAREST WELL ft FOUNDATION uu�A ft PROPERTY ALft 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 RL16F&AND REGULATIONS OF SAN JOAQUIN COUNTY. SIGNED DATE / 2 2/—.? DEPARTMENT.USF ONLY / Application Accepted By z Date 12 d1, ;W1 Area y �� Employee ID#y Final Inspection By Date ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of *t: it/Sump Soil Character: COMMENTS `�nrTc ?gylk to �e- �Jestr��Peol F-Y)Svte thO &i Alt�o0m Is r�n►l�cifri� � �i►�ot17Fr sCO�,L (z}In�rv.1 t'se tank sh�,Il nvi be o1 t�y'P� or r,FerIS fo tepb�ced, Do nod ane if 1hefe 4-611 ;-� not �-� SE12H s PE Code SC INFO Receiveif B Amount Remitted Date Permit/ Aervice Request # Invoice # Permit ID# o7s`isa i2Zf 21 00 14 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18