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CX- ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1863 E. HAZELTON AVENUE - STOCKTON r 95205 - (209) 468-3420 NON-REFUNDABLE ' PEyR..MIITy GALL (2UY 45. 3-7687 FOR INSPECTIONS / LX/P�IRES I YEAR FROM DATE ISSUEI JOB ADDRESS 1 ��!+% 7 !�� 7 V `A�,A✓ • %�� A%o 1 S _ CIT't/ZIP God - ! A- / J CROSS STREET IC 0T� YI jk, 409 APIN ~Ova ` C)' PARCEL, IZE OWNER NAME %--LfAq OWNER ADDRESS 6 1 / CONTRACTOR "II -11 1P CONTRACTOR ADDRESS LICENSE Ll P-42 ❑ C-36 OTHER NUMBER L EXPIRATION DATE - 11 % 1 � WATER TABLE DEPTH:J �- J ft GEOGRAPHICAL INFORMATION: Coordinates X _ Y -- FF PERC TEST #_ BUILDING PERMIT #_. LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE L COMMERCIAL L1 OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG Till S-tIvl'1 CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY _ gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) l� LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES �� / ft Date Permit! Service Reuest # DISTANCE TO NEAREST WELL 4 ft FOUNDATION ft PROPERTY LINE ZlJ 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 / 1 WIDTH ft LENGTH / ft DEPTH o ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE !�V0 ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft �f DISTANCE TO NEAREST WELL ft FOUNDATION _ ft PROPERTY LINE ft SI 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 0 TITL I - DATE &' ' S % J- Iez-&- I�EPARTMENTUSt ONLY Application Accepted8+� ��l N, Date ( Area l�.'I " L " L_ Employee ID# C Final Inspection By _ 1+SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS (114413- f�,1"V +"204'Xx Dc-�'jt�CM4s - A) CS' 4 L/ rL-L -w N e-1 AF- ff-At.F-- Tl' A -C lr=-� l S -O F% CU c -t/-/ O A -t &r.v.�f L_ PE Code SC INFO Rece hec Cash Amount emitted Date Permit! Service Reuest # Invoice # Permit ID# - 1 1 _Cl cR� 7 -J� 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12