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ONSITE WASTEWATER �REATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT c /J /CALL 2099953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS - j� S / S. �3;'l�I�!►� CITY/ZIP Trzlf <br />CROSSSTREET Ulmer kAm rerr(I APN 2-2-55—QC'W-2-0 PARCEL SIZE 7 7AcC'(-> <br />OWNER NAME &'C ]`h �f/ / S-ne, (P PHONE <br />OWNERADDRESS CITY/STATE/ZIP%*V-, Ea`7�=5 <br />CONTRACTOR PHONE ole - %/q <br />CONTRACTOR ADDRESS / U � TAG� Ci CITY/STATE/ZIP'T� Cg Ci15 -37 t <br />LICENSE ❑ 'C-42 ❑ iC-36 OTHER 3 NUMBER SS�7mc S % EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Ci <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: I NEW INSTALLATION '%- REPAIR/ADDITION <br />X <br />Y <br />AND USE APPLICATION # <br />ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM )< DESTRUCTION OL- 'TAN LL <br />INSTALLATION WILL SERVE: ❑ RESIDENCE IJ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG E'L rO/ICrG ?lp_ .- <br />CAPACITY /SDo <br />gal <br /># OF COMPARTMENTS Z <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal <br /># OF COMPARTMENTS <br />FOUNDATION <br />DISTANCE TO NEAREST: WELL SU L`l, w <br />ft FOUNDATION <br />ft <br />PROPERTY LINE It <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES F1 LEACHING CHAMBERS y # OF LINES LENGTH OF LINES ' L' 7�Uft <br />DISTANCE TO NEAREST <br />WELL (,DO ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED WIDTH <br />ft LENGTH <br />Invoice # <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL_____ ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH _ _ <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS WIDTH <br />_ ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL_ ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS NUMBER <br />_ WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />SIGNED <br />Application Accepted <br />Final Inspection By/ <br />Character of Soil to D <br />COMMENTS 61 <br />FOR <br />Date <br />r3� <br />Date -A4 <br />h of 3 Ft: <br />Fog- 1e•Ld-4040EL op F10S'-iiroi <br />f AEA <br />TITLE &W r % u' DATE S- /3 _ / 7 <br />v <br />v <br />z <br />ISE ONLY ' A�l <br />t3 L17 Area Employee ID# 7">K/6440UC42C <br />SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />1ES1 o( -D SAIMC- LLA -AZA -1 <br />0- 12-12-Crbl . &7--) ojgP-174 — A O""7-0aAeS <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount Date <br />Remitted <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />4 2-1 <br />L I S <br />306 <br />2s 1. �.3 <br />SFZ H <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />