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ONSITE WASTEWATER TREX(VENT SYSTEM PERMIT jo " SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - S rOCKTON CA 95205 - (209) 468-3420 NON-REFUN P IT CALL 209 953=7697 FOR INSPECTION EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS n_ CROSS STREEXP,--Ko ah V CITY21P APN QS 5— 13O 9-3 PARCEL SIZE • 33 2 OWNER NAME V I/OQ lA- 61 L� PHONE 351-5M, OWNER ADDRESS J ! l�rJ D ___-_CITY/STATE/ZIP 3zCU l lJ*,J U,5L I CONTRACTOR D CONTRACTOR ADDRESSjrOW v PHONE _� 16 -q607 VN� LICENSE Nl�, C-42 11 C-36 OTHER NUMBER M –EXPIRATION DATE- ❑ GREASE TRAP TYPE/MFG _. WATER �w SC INFO Received B TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y Date ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # Permit ID# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT _ OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ` RESIDENCE LI COMMERCIAL 1 1 OTHER NUMBER OF LIVING UNITS: l NUMBER OF BEDROOMS: 3__ NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY 16 On cit& gal # OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG _. _ _ CAPACITY gal # OF COMPARTMENTS �y DISTANCE TO NEAREST: WELL J ft FOUNDATION Q4 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 e �w ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE` '•-+ ft ❑ SUMPS WIDTH 5 .� ` ft LENGTH ft DEPTH ' ft DISTANCE TO NEAREST SS WELL ft FOUNDATION ft PROPERTYL ft ❑ DISPOSAL PONDS WIDTH _ ft LENGTH ft DEPTH �EANVIROIVAtl Q ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE n UEPART�n�L_ 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. 24 D TICE REQUIRED FOR I ION - LEASE CALL 209 913-76R7 SIGNED n TITLE ,U DATE 961177 VA I I DEPARTMEN U E ONLY Application Accepted By Date _1_ Area W� Employee 0#1� 49 __ Final Inspection By ate_f �- �( I F1 SPECIAL PERMIT -Approved by Character of Soil to Depth o Ft: _ PIUSump Soil Character: COMMENTSVM t I =SVVp DZ-P&DI015 d`N C&P0 tROtJ yt PE Code SC INFO Received B hec s Amount Remitted _ Date Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12