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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 NON-KEFUNDABLE FERMI/ JOB ADDRESS 17 `-16,47 t.l CROSS STREET L. 4 "1 OWNER NAME r ✓� 90J -/0V/ FOR INSPECTIONS tXPIRES l T EAR FROM L)AII E I55t1E1 CITY/ZIP APN ?, I % �� PARCEL SIZE {(G V' �7 L/ PHONES ;1,UC� - "`" ✓ �) 44, 23 OWNER ADDRESS CITY/STATE/ZIP l J CONTRACTOR c,Ciw-I YL�/I��S �I2 ��/ PHONE ('2,,,2) C'1 . 3S C G73 CONTRACTOR ADDRESS / _ [ C o L", /fit � `I'd L �d CITY/STATE/ZIP LICENSE DEC -42 y C-36 OTHE� NUMBERIi.3q qC j EXPIRATION DATE WATER TABLE DEPTH: I '1 ft GEOGRAPHICAL INFORMATION: Coordinates X Y i-1 PERC TEST # BUILDING PERMIT # 0 4, LAND USE APPLICATION # TYPE OF WORK: y^C NEW INSTALLATIONI REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT i OUT -OF -SERVICE SEPTIC SYSTEM i I DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG1 f �Fi -S C' ✓l CAPACITY . L L �" gal # OF COMPARTMENTS 2- ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS SLS I DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS Check#/ Amount Remitted # OF LINES Permit/ Service Request # LENGTH OF LINES ft '4Z1S SLS I DISTANCE TO NEAREST WELL 551. G' 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 0 ft LENGTH ) 3 LJ ft DEPTH ft _ �I 57-r(A '� _5 DISTANCE TO NEAREST WELL ) &(-; ft FOUNDATION ft PROPERTY LINE 5 ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED �2Z< TITLE �X,C ,-(" "s6, DATE a/ I--, //F' �'DEPARTMENT'US ONLY Application Accepted By �� — Date / ry Final Inspection By 61:�Date 3 l Ste! (rte Character of Soil to Depth of 3 Ft: ` Pit/Sump Soij C COMMENTS -1/ %(, A!c~x �r,•tC1 :vt�'��ti'� Area -�7 Employee ID# ❑ SPECIAL PERMIT - Approved by iaracte t1bUy1 Li- 14 � I St lw PE Code Sc INFO Received B Check#/ Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# '4Z1S SLS I 35/ 551. G' 2-Rdl�Y l� -V% 1 I 1 4 -01 � 2N'�. L k' S V y C ctY� �� ( ( a yj ONSITE WASTEWATER TRTMNT SYSTEM PERMIT Sgctirt,MC c4 r