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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-REFUNDABLE PERMIT GALL (20.9)953-7 97FORINSPECTIONS tXPIRES 1 YEAR RO U4TYCISSUED JOB ADDRESS I , ' CITY/ZIP CROSS STREET W i 15� r APN g�-(o��a i PARCEL SIZE OWNER NAME PHONE -71 OWNER ADDRESS 4- / CITY/STATE/ZIP //�-' r + CONTRACTOR I - I//S PHONE Iq IV CONTRACTOR ADDRESS �V �� 576 CITY/STATE/ZIP /�`�L i .'� I LICENSE ❑ 1C-42 ❑ IC -36 OTHER !S NUMBER 1 / EXPIRATION DATE '�61 �7 WATER TABLE DEPTH: 1,0 — 7�A? ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # er LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG �s��at f CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS ft 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 # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft FILTER BED WIDTH ft LENGTH ft DEPTH 1 f f ft DISTANCE TO NEAREST WELL�Iz FOUNDATION IIS ft PROPERTY LINE t l 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 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 It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it 1 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 H UA ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953= 697 SIGNED TITLE 6,j!�14t!: P % zh DATE 1 rA m y v z m C Siv Application Accepted Final Inspection By AW e� , Character of Soil to Depth of 3 Ft: COMMENTS Date � S E Y Area Employee ID# ^�� � edl� i i SPECIAL PERMIT - Approved by Pit/Sump Soil Character: PE Code Sc INFO Received hec Amount ash Remitted Date Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12