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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 r�UN-r[t1-ur4UAtSLt rtMMI I LRLL (LU.9) YOJ-16.91 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE[ JOB ADDRESS ' --r^ p�oi\ `J A!5-_/7�CITY/-Z�IP CROSS STREET C�17 `< ` (�'`�� APNI //`� PARCEL SIZE S�hr► �� OWNER NAME C ^ PHONE OWNER ADDRESS �� C W S 7J ti ' 5 J ( l• if i.i `' CITY/STATE/ZIP CONTRACTOR �V�I `S �:. A ( �-�q ``S�„ 1 N PHONE CONTRACTOR ADDRESS �� N� Xw EI 1 S 7 CITY/STATE/ZIP y� "L4 J LICENSE I C-42 I_' C-36 OTHER IN NUMBER v� EXPIRATION DATE I PE Code SC INFO WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATIN: COord ates X Y PERC TEST # BUILDING PERMIT # ff — LAND USE APPLICATION # TYPE OF WORK: J( NEW INSTALLATION R17PAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: X. RESIDENCE COMMERCIAL I OTHER NUMBER OF LIVING UNITS: 1 ( NUMBER OF BEDROOMS: J NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAP9tl Y 9w gal # OF COMPARTMENTS 2 ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL `�" _ ft FOUNDATION ft PROPERTY LINE lam, ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ,)i, LEACHING CHAMBERS t n� '( #OF LINES LENGTH OFLINES36I ✓L—F ft DISTANCE TO NEAREST WELL 03 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 ft DISTANCE To NEAREST + WELL ft FOUNDATION ft PROPERTY LINE ft r SUMPS WIDTH 4 ft LENGTH I'A ' ft DEPTH b � ft DISTANCE TO NEAREST WELL a% ft FOUNDATION 10" ft PROPERTY LINE + 0 1 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 It 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. MINIMUM 24 HOUR ADVANCE NOT10E REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE Rik S"T3 DATE A r .� O a p vt �S 30 N _ `p ,R 2!6'( / DEPARTMENT USE ONLY L Application Accepted By 1`- Date I �� !' Area . ` e Employee ID# I Final Inspection By Date ��/Go�Z-d' i SPECIAL PERM T - Appr ved by Character of Soil to Depth of 3 Ft: �� Pit/Sump Soil Character: .Gly/ 5a ftd w AQa COMMENTS CO 1cr✓1 ((.h��lC 1�I,,�)-mn -000 gnk� 3-�O [L 4 3 �'4m�s . PE Code SC INFO Received B heck Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 0 l/ 7D S-;