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/'d = Z: :Ty lhA� Scan jjjqjl-7 A�"�✓ a ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 11� ly-IiEF GA 09 953-7697 FOR INS ECTION E ES 1 Y A FRO ATEISSUE JOB ADDRESS Cij p �,,�� % � ITY/ZIP .e /� CROSS STREET.`�� 1057 APN©2- ^ t+Q V � PARCEL SIZE ,0 OWNER NAM ou -+SIV OTPct — PHONL-- 17" I OWNER ADDRESS , [ —CITY/STATE/Z LAS 1rJAJ 1' CONTRACTOR/� • bLl Q��Iv` 7 Vic PHONE 07_ CONTRACTOR ADDRESS�� WCITY/STATE/ZIP 0 LICENSE )( C-42 D C-36 OTHER NUMBER EXPIRATION DATE ' ` 1 'f— ( --) .l' 7 WATER TABLE DEPTH: 4" U ft GEOGRAPHICAL INFORMATION: Coordinates X Y .1 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 ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: _ 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG �'/ �-+ CAPACITYIn gal # OF COMPARTMENTS GREASE TRAP TYPE/MFG C�/'� CAPACITY .} gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL 56 + ft FOUNDATION • ft PROPERTY LINE 50T1 ft ❑ LIFT STATION SIZE _ TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) SiGNED\LVL1 " / 1' \Aj U�1J TITLE VJ W 'J DATE' L=K3 Application Accepted By Final Inspection By Character of Soil to D�pt COMMENTS F"-% fes' PE Code LEACH LINES LEACHING CHAMBERS # OF LINES L- LENGTH OF LINES O / ft Date 240 Invoice # Permit ID# DISTANCE 70 NEAREST WELL It FOUNDATION ft PROPERTY LINE_ ❑ FILTER BED WIDTH It LE ft DEPTH _ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ SUMPS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ DISPOSAL 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. IMlly/171 [� 1 on 140114 Ar1Qw&c-wn-Tjr PAnmPxrn ;rnp INk9E C - 1A — CF rAI I /9nAI 094_7,Ca7 SiGNED\LVL1 " / 1' \Aj U�1J TITLE VJ W 'J DATE' L=K3 Application Accepted By Final Inspection By Character of Soil to D�pt COMMENTS F"-% fes' PE Code SC INFO Received hec B ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 5 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12 T