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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 NUN-KEFUNDABLE PERMIT GALL (ZU'JJ VbJ-1b&1 FOR INSPECTIONS tXPIIRES 1 YEAR FROM DATE ISSUEI / JOB ADDRESS lLS> D E_ S I ALT . I Z q CITY/ZIP I -D LD' I 1 S Z `i- @ �,J. CROSSSTREET KE NN,�ppD,� APN 049 - %-7-o - 04 /_PARCEL SIZE G��/` *� A OWNER NAME F��E1�•�+\)1] 1 �"�� CC� PHONE �F^��-q�0-7 CTa'/NE OWNER ADDRESS (POO E. Ps N f ST . CITY/STATE/ZIP L.'01> 1 C �1 (� 2,40 CONTRACTOR( -t E- �I�1L C7'�D �i �.OT�P1'✓i EJ'V'j 1� L- PHONE 3 L !� CONTRACTOR ADDRESS 4L W O+°�K S CITY/STATE/ZIP LOD C 9��yy LICENSE 0!.':C-42 ❑I C-36 OTHER C -E NUMBER 71s- I EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # I $6ILDING PERMIT # LAND USE APPLICATION # PA --2-11) O -4,15, TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION [.; ENGINEER DESIGNED /ALTERNATIVE i! REPLACEMENT .... OUT -OF -SERVICE SEPTIC SYSTEM I::i DESTRUCTIONS INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ 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 ft 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 ftA V SC DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ^ N T t�fCV 13^I FILTER BED WIDTH ft LENGTH S rvice Request # ft DEPTH ft CIV ED 5 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft PR 0 4 2022 DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH c� A ft DEPTH SASJOAQUIN Mft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE E -N IRON COUNTY ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH HE AL H DEPARTMENT DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft NT ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft I HEREBY CERTIFY THAT 1 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 4QjOUR AD CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 P2o� "K& `f - `F -?.`-�- SIGNED - TITLE -r" - DATE DEPARTMENT US11E ONLY L� J Application AcceptADep 1 Date L� Area I Employee ID# Fr' -9 ✓I K Final Inspection By Date ❑ SPECIAL PERMIT - Approved by Character of Soil to�of 3 Ft:.�}�1 Pit/SUmp So'I Character: N _ COMMENTS Oyq-ie.pcx 'T "r 1eY- ! L0 �2— �= 1 ✓�Yy` (yl 1 � 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 PE SC Received k# Amount Date Permit/ Invoice # Permit ID# Code INFO B Cash _ Remitted S rvice Request # L PD,4 Sa 3 E '' 5 ZL Ijc,GICIZ 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18