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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT 10/0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 11ON-REFUNDABLE PERMIT GALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE[ JOB ADDRESS t J , �l Yo/ � CIIjv/TYY//ZZIIZP • tv) t' �- i S 3 "CROSS STREET 'V r� r � LAJC f , APN �' — PARCEL SIZE 0 - v `- OWNER NAME �1F'L�P` i �rSV I D P, t H lCheji-.3 5 _Ir PHONE be ( - �1,3 i-7 OWNER ADDRESS ` C - CITY/STATE/ZIP CONTRACTOR Iryi a `ILL tC.IG`L PHONE `-'% ` li' r�L• S CONTRACTOR ADDRESS a-% flX- CITY/STATE/ZIP'S j LICENSE ❑ C-42 ❑ 1 IC -36 OTHERIA NUMBER �.'i� 7 EXPIRATION DATE_' 0 J t WATER TABLE DEPTH: Ar/ (C) ft GEOGRAPHICAL INFORMATION: Coordinates X V ❑ 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: e'llESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: . NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG _�E 1 '}1�/V`Q _ CAPACITY ❑ GREASE TRAP TYPE/MFG CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) PJB LEACH LINES 1 I LEACHING CHAMBERS # OF LINES t LENGTH OF LINES t�ii�'� f ft Amount Remitted DISTANCE TO NEAREST WELL r'h.>' ft FOUNDATION 0` 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 ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE 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. SIGNED MINIMUM 24 HOUR44DVANCE NOTICE REQUIRED FOR INSPECTIONS - TITLE <:�n�� - DATE 1 *� ULrAHIMCIVI Application Accepted By Date Final Inspection By 'r Date Z Character of Soil to Depth of 3 Ft:+ COMMENTS 1111/ l!jA(V7-0A-l% Area 6 Alf, II SPE Pit/Sump Soil Character: ( !1v1 Employee ID AL PERMIT - Approved by PE Code Sc INFO Received By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12