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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 (;ALL (209) 953-7697 FOR INSPECTIONS JOBTADDRESS 500 �0fN0 _ CITY/ZIP l.ILy C44 l �� 0 � Z CRASS STREET ,}�1 _ p � � � � � � APN OWNER NAME iCl��E ?�� Ermt7-t _5 57e, Ambo 0 —�y OWNER ADDRE`SS� S A h � A*) A %iy�'� I O B5 I MAVnX// ki CITY/STATE/ZIP CONTRACTORyy �'� �, "'� 1 1 N ` _ PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP EXPIRES 1 YEAR FROM DATE ISSUEI CA q '�?_Vq _ PARCEL SIZE 3 `� PHONE 51-) -7 9 L 0 31 ov `ISZ�r� LICENSE F 1C-42 ❑i C-36 OTHER NUMBER SG"c '7 EXPIRATION DATE__ LJ Z� WATER TABLE DEPTH: 12�1 ft GEOGRAPHICAL INFORMATION: Coordinates X _ J PERC TEST # BUILDING PERMIT # TYPE OF WORK: X NEW INSTALLATION REPLACEMENT LAND USE REPAIR/ADDITION OUT -OF -SERVICE SEPTIC SYSTEM Y ENGINEER DESIGNED DESTRUCTION INSTALLATION WILL SERVE: I_I RESIDENCE *,A, COMMERCIAL D( OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:__ $i SEPTIC TANK TYPE/MFG i" Chec CAPACITY 1 _ gal # OF COMPARTMENTS Permit ID# ❑ GREASE TRAP TYPE/MFG CAPACITY - gal # OF COMPARTMENTS L DISTANCE TO NEAREST: WELL % _J - ft FOUNDATION �� ft PROPERTY LINE Y ft ❑ LIFT STATION SIZE TYPE OF PUMP ____ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft LEACH LINES LEACHING CHAMBERS # OF LINES r LENGTH OF LINES DISTANCE TO NEAREST WELL ft FOUNDATION 5`Ti _ ft PROPERTY LINE y ft ❑ FILTER BED WIDTH _ ft LENGTH _ ft DEPTH ft DISTANCE TO NEAREST WELL tt 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 ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ---ft PROPERTY LINE ft L3DISPOSAL 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. SIGNED Application Ar_.repted By \!6 Final Inspection By� Character of Soil to Depth of 3 Ft: COMMENTSFCLCG Ap'l m 1 v) DATE '-) - i w DEPARTMENT VSE ONLY Date_ d �kreu LIIIpIJyGF Ii+r " 1 Date 1G El SPECIAL P RMIT -Approved by Pit/Sump Soil Character: _ PE � Code SC INFO Received B Chec Amount hermit/ Date Remitted Service Request # I Invoice # Permit ID# — L _ 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12 117