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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 ['JUN-rStI-UNUAULt rtHMI I _ _ ■-m+ •. IN•J/ JJJ-/O`J/ FUH INSPECTIONS tXPIRES I TEAR FRUM UATE ISSUEI JOB ADDRESS _ pq LAC), CrryMP CROSS STREET -Real Tw AM U y PARCEL SIZE OWNER NAME P�A((�1A/.�r I i� T . PHONE (� OWNER ADDRESS r� //syy V (,LA I' ►`I �.�A�P Lod; ( —175.1 � U CONTRACTOR .. h..�rY. I V� IG�/[�1I l - PHONE CONTRACTORADDRESSa3 I G. (J sa I^ t>,-- _ �j Crry/STATEfZIP ,, � C%YJ��ZT�j/�j9 �✓ �� LICENSE I " C-36 OTHER NUMBER ��q--0q EXPIRATON DATE ! _✓�+ �v _ WATER TABLE DEPTH: 7 J/ ft GEOGRAPMCALINFORMATON: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIWADDInON ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER NUMBER OF LIVING UMTS: _._I NUMBER OF BEDROOMS: _ NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPFJMFG Z=V My ❑ GREASETRAP TYPHMFG DINTANCETo NEAREST: WELL ❑ LIFT STATION Sim TYPE OF PUMP CAPACITY gal # OF COMPARTMENTS CAPACITY gal #OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE —ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) O LEACH LINES xLEACHIMCHAMBERS IO 4644ML10-1 #OFLINES LENGTHOFIUNES JO' ft DwANCETO NEAREST . ' ft FOUNDATION _-5_ft PROPERTY LINE CAS, ft ❑ FILTER BED WmH It LENGTH Code ft DEPTH ft Date Invoice# PermRIDN Remitted Service R ue5t i y�U DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL If FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER pZ w H ft DEPTH ft DISTANCE TO NEAREST WELL it FOUNDATION .S _ ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN J 0 A 0 U I N COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. ■! l.�111lL■#■■I■■■■■I■■I iiiiii■iiiii�il■■■I■■I Application Accepted By Final Inspection By Character of Soil to Depth of 3 COMMENTS i. TITLE DATE �— TMENT USE ON Y ��/1 Date 7 0' ) Area '� �Q C Employee ID# "— U n Date SPECIAL PERMIT - Approved by PhtSump Soil Character: PE SC Received Check#/ Amount Permit/ Code INFO Cash Date Invoice# PermRIDN Remitted Service R ue5t i y�U IS `f1 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 424/12