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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 209 953-7697FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1390 T �/1 LQ W• (-tr,4,-f YI n r V'K CITY(ZIP l .G u _ CROSS STREET t--Q M tyl ey-5 APIN z— O� PARCEL SIZE �2.Z2 CA D 0 0 , �. P_ >o OWNER NAME AIJs� GI I � L PHONE OWNER ADDRESS O 2 O ewOGL1+ CI-04CI- D11 CITYISTATERIP �f Q Q-796- CONTRACTOR Qe�� CONTRACTOR t - n^�D. PHONE `D I- ?C Q-7 - �'') CONTRACTOR ADDRESS 392- V CTI/ra,C -S D�/� CITYISTATE/ZIP __ f^1/1 fM[lP.S7`o /S✓J to LICENSE QC-42 QC-36 OTHER C-`l NUMBER�vEXPIRATION DATE / _J 1` `0 WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y G PERC TEST # I BUILDING PERMIT If ____ LAND USE APPL TION# TYPE OF WORK: I, NEW INSTALLATION I REPAIR/ADDITION ENG/ EER DESIGNED/ALTERNATIVE i REPLACEMENT OUT-0F-SERVICE SEPTIC SYSTEM DE INSTALLATION WILL SERVE: O RESIDENCE i I COMMERCIAL U ER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPF_rMrG CAPACITY gal #Or COM.PARTMENTS_-_- ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCETO NEAREST: WELL ft FOUNDATION it PROPE111YLINE ft O LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES f LEACHING CHAMBERS #OF LINES LENGTH OF LINES _it DISTANCE TO NEAREST WELL It FOUNDATION It PROPLH r LINE it ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL II FOUNDATION ft PROPERTY LINE it ❑ MOUNDED WIDTH It LENGTH _- it Oranl it DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE_ it ❑ SUMPS WIDTH ft LrNGT1I ft DEPTH tt DISTANCE TO NEAREST WELL ft FOLNDAT.ON ft PROPERTY LINE It ❑ DISPOSALPONDS WIDTH It LENGTH ft DEPTH Il DISTANCE TO NEAREST WELL ft FOUNDATION _ft PROPERTY LINE R ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH R DISTANCE TO NEAREST WFI I It FOUNDATION ft PROPERTY LINE -. R I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIARAeV HOUR CE NOTICE REQUIRED FOR INSP CTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE r C(A _ DATE 9-16- 113 i r j I _ _ ——{--- -- — _- -- N O D 1 C U DEPARTMENT USE ONLY /_ Application Accepted I�1/1� Date 6 9i Area C Employee ID#7e IR�c Final Inspection Date L1 SPECIAL PERMIT-Approved by Character of Solfto h 3 F. ItlSump Soil Chara _ COMMENTSu PE SC Received eck#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B Remitted Sery co Re uest# ZM P25 0 4 tog 42-01 ONSITE WASTEWATER TRTMNT SYSTEM YLHMI"T 41'24P2