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r` ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1�0 4 /�4 C_ o llier IZUe-/G/ CITY/ZIPL�,� C r" H til CROSS STREET PN f\' I A P N -O PARCEL SIZE �� C dAOWNER NAME PHONE 34�9—02(le 7/ OWNER ADDRESS p J�� r I I Sn,n CITYISTATEIZIP !,� z a CONTRACTOR �[ V) l 7r `1 I �/ a tr�� PHONE �O �r u1'0 CONTRACTOR ADDRESS � �I SUv, ��• CITY/STATE/ZIP C� 1 (64 LICENSE ❑�-42 ❑❑C-36 OTHER NUMBER 7 S�C75 EXPIRATION DATE % — -?1-19 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # DUILDING PERMIT# LAND USE APPLICATION# d' G` TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION LI ENGINEER DE �1p� ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION ��y{ &&�� INSTALLATION WILL SERVE: RESIDENCE 11 COMMERCIAL ❑ OTHER 9 NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF ESM Y�/�p ❑ SEPTIC TANK TYPE/MFG �i S//r1�) CAPACITY gal #OF Q tNQPNpTe„_ MEN ,N� ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMGENTS'RTAAE11 I DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ® SAND OIL SEPARATOR(ENC/LO/SED SYSTEM) LEACH LINES ❑ LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES 7 d ft DISTANCE TO NEAREST WELL ft FOUNDATION ��j ft PROPERTY LINE �s 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 fl 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 PROPERTYLINEft SEEPAGE PITS NUMBER C;z WIDTH / ft DEPTH �`, f ft DISTANCE TO NEAREST WELL 5 O ft FOUNDATION Jr6 ft PROPERTY LINE 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-77697 SIGNED — TITLE DATE D p , u S a PARTMENT UXSE dNhY Application Accepted By Date f Area Employee ID# w Final Inspection By � ✓�� Date I I�ILi � I ❑ SPE IAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received heck-RD Amount Date Permit/ Invoice# Permit ID# Code INFO By emitted S rvice Request# a2 it d 5 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12