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a ONSITE WASTEWATER TREATMENT SYS"TE15fl PEERNT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)463-3420 NON-REFUNDABLE PERMIT -- CALL C201T 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS r �`� —_ CITY/ZIP 6VX-Kofa1 CROSS STREET —�uj� —. APN / /J PARCEL SIZE �1 1 OWNER NAME t-t/vchd,e.ST}' GLy PHONE --- v; OWNER ADDRESS cdi^+� _ CITY/STATEIZIP CONTRACTOR—IM 16 VeWb a_-e— J Q f=_ —`- PHONE -- CONTRACTOR ADDRESS / 0 6* / —CITY/STATE/ZIP M�—^ft*r� LICENSE 1-11-IC-42 I IFIC-36 OTHER— NUMBER (Y,7 EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y r ❑ PERC TEST # BUILDING PERMIT#�—_ ''LAND USE APPLICATION�# --TYPE OF WORK: CI MEW INSTALLATION REPAIR/ADDITION CI ENGINEER DESIGNED/ALTERNATIVE I REPLACEMENT I I OUT-OF-SERVICE SEPTIC SYSTEM Li DESTRUCTION _ INSTALLATION WILL SERVE: L�SIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: U SEPTIC TANK TYPE/MFG _--_ CAPACITY gal #OF COMPARTMENTS GREASE TRAP TYPE/MFG .—. CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft < LIFT STATION SIZE TYPE OF PUMP_— M PKG TX PLANT Q SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES I.1 LEACHING CHAMBERS— IIt OF LINES C�t LENGTH OF LINES L10 _ It DISTANCE TO NEAREST WELL 1{U 1 ft FOUNDATION_ 10 _ _ft PROPERTY LINE_ /4 ft 1?3 FILTER BED INIDTI-I ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft MOUNDED WIDTH ft LENGTH it, 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 t PROPERTY LINE ft 13 DISPOSAL PONDS WIDTH ft LENGTH_ rt DEPTH ft DISTANCE TO NEAREST WELL �j ft FOUNDATION ft PROPERTY LINE ft EF-PAGEPITS NUMBER 4 WIDTH ✓� a) _ft DEPTH.��` ft DISTANCE TO NEAREST WELL ) ft FOUNDATION �� r �'it PROPERTY LINE `IS ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, SPATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. Ali 1�1�ty1_QiW iL PI ?D .�1 DANCE NOTICE E-dJIRED FOR INSPECTIONS - PLEASECALL (209)PP953-7697 c SIGNED TITLE `-�FJ� ��{ DATE �P I O M N AI- T DEP PARTMENT USE.ONLY Application Accepted By -- Date Area _ l_—� Employee ID# Final Inspection By Date_ V�1 � El SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: _ /Sump Soil C iaracter. COMMENT" ►�� PE SC Received Check#/ Amount Permit/ Invoice# Permit ID# Code INFO a r _Cush Remitted Date Service Re uest## ' -�� - X00 42-01 ONSITE WASTEWATER.TRTMNT SYSTEM PERMIT 4/1A/i/I