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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 /,7,GAL—L7 209 953-76'.x/, /FOR INSPECTIONS LXPIRES 1 YEAR FROM LIATE ISSUED JOB ADDRESS IAMO L.9- �4> 17 avo E • H w Y I 2,u CITY/ZIP 40F G'4� ( -53 (-f - CROSS STREET �/ � �%� p� �f� APN 2- — PARCEL SIZE 16-4 - tI OWNER NAME w t A.) 1-� T I l PHONE OWNER ADDRESS Po "- tox ( C) CITY/STATE/ZIP S-[ GA q S3 -7t CONTRACTOR � ///7�iIr��/G• PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP ✓` O lo�' /V 175 011 LICENSE ❑ C-42 ❑ C-36 OTHER I NUMBER 7181y3 EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # I TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION /ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM --/DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT ❑ gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft Permit ID# DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH It 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 C� CA 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 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. MINIAR19 E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 9/53-697 SIGNED /�� , .?.tG , -Y 'eL?I/ TITLE _ .QF�r✓ _ �i¢{L/�7� DATE _ 17,ll Application Accepted By _ Final Inspection By t_IZ�rMCter of Spit to Depth of 3 Ft: COMMENTS h T DEPARTMENT USEiONLY Dale Gi L"If _ Ai,a �1 _ Erni'!,?wsp.I7E.`;�!TS[©�act_L�S Date zO/ ❑ SPECIAL PERMIT -Approved by Pit/Sump Soil Character: PE SC Received Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO B C sh Remitted Service Request # 4.2 USS �' Ill • � � � Z� C� CA 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12