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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-REFUNDABL PERMI/T CALL 239 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE 6SSUED JOB ADDRESS � �ti �lD I /l `Tt1�I WGY CITY/ZIP *,- C- L y CROSS STREET O e,160 f\ !q(3 APNiI a S 0� 1 3S PARCEL SIZE d [3o OWNER NAME Imo/,! • S!UA PHO / �r /�y� �� N�E ! ✓� q vii OWNER ADDRESS �^n� 11 T /V `�V vY CITY/STATE/ZIP �yQ�(y�4iG CONTRACTOR VI 111J�-�S ��+�� KIj,��/- �'+ PHONE `/ (� O`�' r CONTRACTOR ADDRESS i0c) ?60h- (y �V CITY/STATE/ZIP 4.,f- LICENSE 1111C-42 110C-36 OTHER Y 1 NUMBER&6SS�5-9 EXPIRATION DATE O MAYR WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X YRECIElln ❑ PERC TEST # BUILDING PERMIT# 1 I LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LI ENGINEER DESIM,1r-fy/ALT0RNM8 ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCT INSTALLATION WILL SERVE: RESIDENCE 11COMMERCIAL ❑ OTHER EAM NTy NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: / NUMBER OF EMPLOY .ki DEPAE�#C_ SEPTIC TANK TYPE/MFG �T Z- CAPACITY L gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL 1001 ft FOUNDATION / ft PROPERTY LINE S�r ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES ❑ LEACHING CHAMBERS / #OF LINES 3 LENGTH OF LINES SS ! ft / DISTANCE TO NEAREST WELL 00� ft FOUNDATION 7S- 1 ft PROPERTY LINE 60 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 I ft FOUNDATION ft PROPERTY LINE ft � SEEPAGE PITS NUMBER 3 WIDTH ",;L(I ft DEPTH ,4:57' ft DISTANCE TO NEAREST WELL I.jOI ft FOUNDATION IftQ j_ft PROPERTY LINE 0 I ft 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 ` OHO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 9153-7697 G SIGNED TITLE 60fff-1.4 DATE l EPARTME T U E O Application Accepted By Date Area Employee ID# Final Inspection By /' Date i146J20,j ❑ SPECIAL PERMIT-Approved by '> / Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received Checic#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B Cash Remitted Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12