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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - S'TOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE JOB ADDRESS -7 1 f"!11 mil lam, 11 4` 10 IF 1111 1&1 CITY/ZIP CROSS STREET aC s ✓�M?CiN' - APN 6�-�UlJ 7r PARCEL SIZE E OWNER NAME tl��>r/ r/ 1��L.^'lCy �u? PHONE I % `iIC�%` yGeZ�L^I �.J OWNER ADDRESS '^ ��G'-y S'1— CITY/STATE/ZIP CONTRACTOR WA J ` PHONE Ll 5b 5 SCCP�i CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-42 ❑ C-36 OTHER NUMBER ,iesI EXPIRATION DATE ! WATER TABLE DEPTH: rili L o ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ 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: VRESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: P1"*`SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG NUMBER OF BEDROOMS: DISTANCE TO NEAREST: WELL "3 1 ft ❑ LIFT STATION SIZE TYPE OF PUMP NUMBER OF EMPLOYEES: CAPACITY / , l_ gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS FOUNDATION 7 ft PROPERTY LINE / ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES 410,11-1 ! ft Chtakkb ash DISTANCE TO NEAREST WELL If ft FOUNDATION ft PROPERTY LINE _�O(,I ft Q FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE X.1 A it E3MOUNDED WIDTH ft LENGTH ft DEPTH dLw `Ai1V� DISTANCE TO NEAREST WELL ft i FOUNDATION ft PROPERTY LINE f,L ❑ SUMPS WIDTH ft LENGTH ft DEPTH i[�) DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN It ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ��O It 4ZIVVDISTANCE �ROIVI_Uc _UNTft TO NEAREST WELL ft FOUNDATION ft PROPERTY LIf�l 1 P'gRT SEEPAGE PITS NUMBER 14 WIDTH 3& It ft DEPTH . ft DISTANCE TO NEAREST WELL% C : ft FOUNDATION P ft PROPERTY LINE l 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. IVIIIYI/YIVIVI 9. IIV n L.,V IVLIL- IYV I I{.ic nCVIVInL-L/ rVn /IY17rC{0 I IV/YJ - rLCP10G L.RL-L_ Izu SIGNED TITLE 6.4"V4 DATE .DEPARTMENT US ON yv/ Application Accepted By Date Area Employee ID#� Final Inspection By !� Date ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of t: Pit/Sump Soil Character: COMMENTS PE SC INFO Received B By, Chtakkb ash Amount Remitted Date Permit/Code Service Request # Invoice # Permit ID# V, r)a - 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12