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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-REFUNDABLE PERMIT (�CALL 209 953-7697 FOR INSPECTIONS /�( EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS V-`12- �N.,, ^,�R 1\� 7 CITY/ZIP rK I1� / (' J 3 u' CROSS STREET NO I•V I� �V I �Q �y�' V APN�J�Z6 W /PAARRCEL(SnIZE g OWNER NAME I t jG� T 'tt V /PPHO`N�E 20q- I-v LT-1 M I� OWNER ADDRErSSS V V� '_Xi11]IU)/� /�/�iWyy�r�, (• `/� ,,y��t CFTY/STATE/LP -VM �l� CONTRACTOR I O V x--'fy�V 1j °�A If/ Qe `� I l.{4 I11 PHONE 2jA rn 2- - I o-1 CONTRACTOR ADDRESS (^ CITY/STATEIZIP LICENSE I l C-42 11 C-36 OTHER G�� PK NUMBER " s i`+' EXPIRATION DATE � Ly�U tEL WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE --� REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM ICI DESTRUCTION INSTALLATION WILL SERVE: 1 RESIDENCE L COMMERCIAL I 1 OTHER V� NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES 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 f J ❑ 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 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-763397 SIGNED TITLE l- CL DATE 7 afiN ENT IVSD 4 2919 SAN J A U N COUNTY E IR MENTAL H LT ARTMENT DEPARTMENTYSEONLY. _ Application Accepted B. Date Area ployee ID# Final Inspection By \i DateI LIN SPE AL'PERMIT-Approved by Character of Soil to Deoth A3 Ft: Pit/Sum Soil Cl racter: COMMENTS LA I1-rn (f'C)f-c-ec'f PE SC Received Check Amount Date Perm Invoice# Permit ID# Code INFO By as Remitted Service Re uest# Z2-( l t—► /� c i 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12