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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 GALL (2UY) 95: JOB ADDRESS 4747- E • wr.I>OAIID&v� 1(g r of EXPIRES 1 YEAR FROM DATE ISSUE ,I PD 9 S"!..'Z.0 CROSS STREETyJ 1 w1 E R- 3 0�0 • / / APN O (3 - ZZV - i 3 * �� PARCEL' + SIZE 3o r OWNER NAME F -A fs W1 S h -h &I A- &0 % e, L.() PHONE (901- I 111 OWNER ADDRESS /F'f0l) C- I+ArJDC L P-0• -CITY/STATE/ZIP /_ LoD I .L� Iy L40 CONTRACTOR W V t •Urr t r GF -Q F hJJ,V(QGNY� C /VT ^ L PHONE -41 - 03• 1, 5 CONTRACTOR ADDRESS �V f/{l - `� (L S ' CITY/STATE/ZIP L p 01) ( C A _( r 2-4 0 LICENSE ":. C-42 11-C-36 OTHER C EU NUMBER �'� ( EXPIRATION DATE 30 2 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # I BUILDING PERMIT # # OF LINES LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION __ REPAIR/ADDITION ,.. ENGINEER DESIGNED/ALTERNATIVE ft FOUNDATION ... REPLACEMENT __ OUT -OF -SERVICE SEPTIC SYSTEM ,.. DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE L COMMERCIAL L OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ft NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS ft LENGTH 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 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 LINE ft ❑ SUMPS WIDTH ft LENGTH It 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. i D E P A R T M E N US k ONLY qlaq Application Accepted By �L� Date r2 Area I Employee ID#� Final Inspection By �!Uy�1 i ,D !It /i�G� Q4-ji L Date /Xi I h,12Z ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO EW Cash Remitted Service Request # �aaa S33 s(, 949.2 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18 TY UT