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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 PERMIT ^ ' (.FILL (LU.4) 40,5-/04/ FOR INSPECTIONS LXPIRESSI TEAR FROM UATE ISSUES JOB ADDRESS �n�� 1 1�1 '✓i l f� Q CITY' /ZIP I ! 0) CROSS STREET Uirw.t QJ/YL - APN 05 2 ,5]0 D ei PARCEL SIZE OWNER NAME �� , G C. n U PaA fvS1PHONE OWNER ADDRESS CITY/STATE/ZIP " l' v/ CONTRACTOR VJ PHONE 5�W - — l CONTRACTOR ADDRESSV 1� i x (J D CITY/STATE/ZIP Y aA x- L4 Q C' /z - q LICENSE (i C-42 I C-36 OTHER NUMBER O/ S5-3 EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y [ I I PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION ,- I REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE � I y REPLACEMENT �Ol I!* IC T -OF -SERVICE SEPTIC SYSTEM k)` DESTRUCTION 1'I,Z INSTALLATION WILL SERVE: J RESIDENCE -, COMMERCIAL _I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:_ SI•PTIC-TANK TYPE/MFG CAPACITY t Ol:�� gal # OF COMPARTMENT% ) ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft LIFT STATION SIZE r TYPE OF PUM� 1-4 , PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES I 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 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 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 1 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. A✓VPIIVIsG IrvIIVC /Tc VI![C1j 1-wn //vorcl./IVIY - r-I-FnaRI.HLL ev, SIGNED Lid, TITLE iIAZ .!1/ �' DATE 0 DEPARI'M = NT USE ON Y � t Application Accepted By Date Area Employee ID# Final Inspection By 4 Date ,1 l I ! SPECIAL PERMIT - Approved by Character of Soil to Dep1h o Ft: Pi Sump Soil Character: COMMENTS *I 1 _ ':,:;(I !_ . • n - PE Code SC INFO Received B hec ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 31 5 � I A° ' s7A S?I 42-01 4/24/12 1 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT