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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-FiEFUNUAtiLE YEHMl II G V LALL ZUY V041-10-41 FUR INSPEG11UNS tXPIHES 1 YEAH FRUM UATE ISSUEI I JOB ADDRESS q 31 -y�l./ oPc1(-�o-o 1-*�> �y CITY/ZIP STUGK-TDTj 7.5-L1, ,Q..� CROSS STREET Am 1�- lT o C APN I a S — �/ - C) (-P PARCEL SIZE GO ' `� • OWNER NAME J E�2y ✓YL �T-Tl-fCWT� PHONE LC OWNER ADDRESS r� 1 ►Z ly EYz �E ^� -C>y�� IZ CITY/STATE/ZIP L- 6T) 1 C-i"i CONTRACTOR �-)y E G-C-C>-CrJV\IZ-Orjn-LL-T� I %KL. PHONE 3&1 - 03-75 Lj CONTRACTOR ADDRESS TO� W - U � S I - CITY/STATE/ZIP L -0-D )I C � `� 2'-y LICENSE C-42 LlI.'.0-38 OTHER C G % NUMBER ZI ( EXPIRATION DATE 4 -3c, -2-4 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST I BUILDING PERMIT # LEACHING CHAMBERS LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION 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 It PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS _ft PROPERTY LINE ft # OF LINES ft DISTANCE TO NEAREST WELL ft ft FOUNDATION_ ❑ FILTER BED WIDTH It PROPERTY LINE ft LENGTH ft It PROPERTY LINE ft DISTANCE TO NEAREST WELL ft ft FOUNDATION ❑ MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL It FOUNDATION ❑ SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION ❑ DISPOSAL PONDS WIDTH ft LENGTH DISTANCE To NEAREST WELL It FOUNDATION ❑ SEEPAGE PITS NUMBER WIDTH DISTANCE TO NEAREST WELL ft FOUNDATION It ft _ LENGTH OF LINES ft _ft PROPERTY LINE ft DEPTH ft _ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft It PROPERTY LINE ft DEPTH ft It PROPERTY LINE ft ft DEPTH ft It 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 I&WOUR AD V4NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209).953-769 SIGNED TITLE P2C)J C-12 DATE Z�' ZZ - DEPARTMENT qSq ONLY Application Accepted By r�2� -- Date Area Employee ID# A Final Inspection By f/A611 r t /d1 454.44a:. A41 Date SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character:..___ COMMENTS PE SC Received Check#/ Amount Permit/ Invoice# PermitlD# Code INFO Cash Remitted Service Request # Laaa sa3 Is z 5a 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18