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' ONSITE WASTEWATER TREATMENT SYSTEM PERMIT xllry � 3� -3 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697FOR 1 PECTIONS EXPIRES 1 YEAR FROM( DATE ISSUE JOB ADDRESS C ✓ CITY/ZIP �.� .S' i L %J, `J e7'3 Z L ❑ LIFT STATION I l/� jj - �� J d t 3 CROSS STREET V' T t�! I�/� APN U PROPERTY LINE ft PARCEL SIZE OWNER NAME �P 1�}^� / �� Z Ir ✓� � nui A Pf Tr PHONE OWNER ADDRESS `�%�� N [ C! ft DEPTH tC ft CITY/STATE/ZIP _ DISTANCE TO NEAREST WELL CONTRACTOR L, APHONE WIDTH ft LENGTH �l J- - DISTANCE TO NEAREST WELL `C L/ // `1 C40— WIDTH ft LENGTH ft DEPTHt4- ft CONTRACTOR ADDRESS / C�%L! (.I. �--c) CITY/STATE/ZIP ��/l �/ LICENSE IJ' C-42 Cl C-36 OTHER / Y 1 NUMBER EXPIRATION DATE d 1 -A 1 MINIMUM 24 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED WATER TABLE DEPTH: 00 i o ft GEOGRAPHICAL INFORMATION ❑ PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION REPAIR/AD! Coordinates X Y LAND USE APPLICATION # IN ENGINEER DESIGNED /AL TERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: It -P RESIDENCE 11 COMMERCIAL I , OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ___. _ NUMBER OF EMPLOYEES: D ❑ SEPTIC TANK TYPE/MFG CAPACITY - _ gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY _ gal # OF COMPARTMENTS P SPECIAL PERMIT - 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 lJ ft DISTANCE TO NEAREST WELL�FOUNDATION PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYL�1 /: ft ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH tC ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY/Li ft L3 SUMPS WIDTH ft LENGTH ft DEPTH 4 2 ft 46 -- DISTANCE TO NEAREST WELL ft FOUNDATION ft PROP%^' -n ft NVA/k�,.-Cot/ ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTHt4- ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERT,LYrLIINEE At ft 13 SEEPAGE PITS NUMBER t"/ WIDTH fL DEPTH 12 � ft DISTANCE TO NEAREST WELL _ y�� tt FOUNDATION �Z,C.tt( PROPERTY LINE ft v - I 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 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE�DATE T RAF Application Accepte B )„ ✓F:"AFiTi1'rf=iv: ii.">., Ob?LY Date r" /� Area �"t qq / ,�1! Employee ID#I_v,�� Final Inspection B Date S P SPECIAL PERMIT - Approved by Character of Soil to epth of Ft: Pit/ it ratter: �C��IMENTS �- �� - — d PE Code SC INFO Received B Che Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12