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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1368 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS�, ti° �t V -jX,J t 1r A %0 AD /� CITY/ZIP 1- � � Z � ; L� CROSS STREET �� S [ ��(�QAl 1^�� /�/�= i4 J APN 651 J �Q O 7 PARCE SIZE OWNER NAME SnO (GnW`� A� 1" IN� / _ _ PHONE OWNER ADDRESS r: E (N 7_w� � CITY/STATE/ZIP CONTRACTOR \ Y E05 1 PHONE .. 3 �� _ 7 �o_c)q CONTRACTOR ADDRESS 3 2 .7 x 1 ` S (_ CITY/STATE/ZIP L C, ' Lz4 LICENSE l C-42 11 C-36 OTHER NUMBER V bi I S EXPIRATION DATE �` -7 3 WATER TABLE DEPTH: L l/ it GEOGRAPHICAL INFORMATIO Coordinates X Y PERC TEST # ___ BUILDING PERMIT #,21�LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: I 1 RESIDENCE X COMMERCIAL 11 OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:. ` SEPTIC TANK TYPE/MFG �'� L' CAPACITY 160 0 gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal It OF COMPARTMENTS ❑ DISTANCE TO NEAREST: WELL 100 _ ft FOUNDATION 2`7 ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBE�NF` �� # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL I ft FOUNDATION ft PROPERTY LINE L w ` it ❑ FILTER BED WIDTH ft LENGTH ft DEPTH PAYMENT— it DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LIQ ECEIVED ft 13 MOUNDED WIDTH ft LENGTH ft DEPTH ftp ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LISEDJCf9 6 7M% it ❑ SUMPS WIDTH ft LENGTH _ ft DEPTH �� cvT�— it DISTANCE TO NEAREST WELL________ it FOUNDATION ft PROPER16MOOAQUIN COUNTYit El DISPOSAL PONDS DISPOSAL WIDTH _ ft LENGTH ft . _ DEPTH ENVIRONMENTAL— DEPARTMENTft DISTANCE To NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE It I$ SEEPAGE PITS NUMBER 7 WIDTH 1l ft DEPTH 2S I it DISTANCE TO NEAREST WELL ft FOUNDATION _ Z, a ft PROPERTY LINE =JD , it 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLE4SE CALL (209) 953-7697 SIGNED �i ""' TITLE_ L.i 1OL--JI-7DATE DEPARTMENT U E 0jfVLY Application Accepted By Date Z Area L4 q-"1 Employee ID# Final Inspection By Date ❑ SPE IAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: PiVSump Soil Character: COMMENTS � �_ ��'Lt4e,4 0Gv/vr1 ll_✓fI_—.. L J-" { 1_1- i- -IL. Cnnw._w A ! J _ _ % L 1�__ 1 I_. •-1! _ _I wMac.x-n A-kn G D , r.w4rA f L-- . .111 ...:.vl_/ L e'L.. Z� me - L4.. 0 — I- A...-4- /_ %1 PE SC Received Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO By Cash Remitted Service Request # :52.0)b7$j`� t 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12 0 1J 1\