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V ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 465-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1 % O 1,1 /' e CITY/ZIP ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH /0 S Z 7 PARCEL SIZE CROSS STREET FOUNDATION APN ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION OWNER NAME 1 Ai�J I PHONE DISTANCE TO NEAREST WELL ft / SEEPAGE PITS NUMBER WIDTH OWNER ADDRESS ft DEPTH 2✓ ` ft CITY/STATE/ZIP FOUNDATION CONTRACTORO �-" ��/4 d ��G�J�%�i-� PHONE /�f[i�� CONTRACTOR ADDRESS / 7 U L� zz;��q%� �� CITY/STATE/ZIP //,�a�/� ��" �✓ -j' J LICENSE ❑1iC-42 ❑11C-36 OTHER /4 NUMBER EXPIRATION DATE WATER TABLE DEPTH: /, 0 / ft GEOGRAPHICAL INFORMATION: COordi ❑ PERC TEST # ' BUILDING PERMIT# O TYPE OF WORK: LL NEW INSTALLATION Li R AIR/ADDITION tes X Y_ LAND USE APPLICATION # LJ ENGINEER DESIGNED ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: A RESIDENCE Ll COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFTSTATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT TERNATIVE gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES kV LEACHING CHAMBERS �� .Z V # OF LINES / LENGTH OF LINES / O ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH Permit/ Service Request # Invoice # ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH IR�/ 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 2✓ ` ft DISTANCE TO NEAREST WELL l�`J 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. SIGNED VIS /IVJrCli 11VIVJ - r-LCNJC %✓FILL I CV -71 .7,JJ-I VJI (/ TITLE DATE / �2— 2 J �� Q Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS /`-)/ 1�) LCli I5 -r- r%ZV--25o" /5I/I5-- A�?� PE SC Received Code INFO BV heck#/ as Amount mitted Date Permit/ Service Request # Invoice # P 5 10 X51s IR�/ 42-01 ONSITE WASTEWATEg AgT�T�1 K W 4124/12 �� ENVIRONMENTAL HEALTH DEPARTMENT T