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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAk:UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT GALL ZUyp FOR INSPECTIONS txPIHtS 1 T tAH UA It: I,JUtl JOB ADDRESS 2�� �Jb:i-/6`J/ I L'Zy / CITY/ZIP th-HUM CROSS STREET TI /� APN /i"L /i�� ? ok-4 � PARCEL SIZE OWNER NAME �' �i , WELL 1,00 ft FOUNDATION _ (I)( 'r ft PROPERTY LINE It PHONE �� OWNER ADDRESS 2 / // '' L�o"v CITY/STATE/ZIP �-I [y iL I I �� WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED CONTRACTOR ft LENGTH ft DEPTH GE=n/r PHONE DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH CONTRACTOR ADDRESS CITY/STATE/ZIP WELL ft FOUNDATION ft PROPERTY LINE '4_ WAI It LICENSE U 'C-42 U C-36 OTHER NUMBER EXPIRATION WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COO ❑ PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION tes X Y LAND USE APPLICATION # ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: )( RESIDENCE ❑ COMMERCIAL /J LJ OTHER NUMBER OF LIVING UNITS: � NVy///)�//�Jf NUMBER OF BEDROOMS: !/ NUMBER OF EMPLOYEES: 1d CFPTIC TANK TVPF/MFr: \ 7i L rAPACITV 1-2-00 rlal If nr ( .r)hAPAGTKAPMTC 10- ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS he ash DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE It ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS # OF LINES �/ LENGTH OF LINES �C J 1 J ft DISTANCE TO NEAREST , WELL 1,00 ft FOUNDATION _ (I)( 'r ft PROPERTY LINE It ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH GE=n/r DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH o. - DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE '4_ WAI It El DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH HEAL,Y%U MEF Pjz-'jL� DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE vL ARTME SEEPAGE PITS NUMBER WIDTH DEPTH 2 ft DISTANCE TO NEAREST eft WELL ft FOUNDATION (J ft PROPERTY LINE h D 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. MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE DATE l\ EPARTMENJUSEONLY Application Accepted B Date I I Area Employee ID#15a�o_ Final Inspection By DateI Z f i g�l '�- 11 SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: �' Pit/Sump Soil Character: COMMENTS _LDT ,aie PE Code SC INFO Received B he ash Amount Rem/ittted Date Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12 U