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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-_7_697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �� y�j _____.__.___ __.___.__ ___CITYIZIP CROSS STREET (SAPNy - 7` 15-01 `T -'----_PARCEL SIZE DTCd----- I*Dl o 0 OWNER NAME..._.� rJ�.-- __.. ___._PHONE r149-30,1- OWNER ADDRESS __ _----_ CITY/STATE/ZZIIIPP') CONTRACTOR +'�f � )l / - ._-S �' PHONE_zi L..1LfGY/ CONTRACTOR ADDRESS 1246A/ Z ______.CITY/STATE/ZIP �[ _� _ __q�� LICENSE �CIC-42 ❑i1C-36 OTHER__ z ' NUMBER g' 7d3 .EXPIRATION DATE- WATER TABLE DEPTH:_ it GEOGRAPHICAL INFORMATION: Coordinates X,._. Y Ll PERC TEST If BUILDING PERMIT it . _. - ._ LAND USE APPLICATION TYPE OF WORK: I NEW INSTALLATION >iC REPAIR/ADDITION 11 ENGINEER DESIGNED/ALATIVE 1) REPLACEMENT __ 1.1 OUT-OF-SERVICE SEPTIC SYSTEM X--TE(INDESTRUCTION A 2A-ALL INSTALLATION WILL SERVE: QARESIDENCE I 1 COMMERCIAL I I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: tt SEPTIC TANK TYPE/MFG _ __.__ i _ CAPACITY__, �y _ gal #OF COMPARTMENTS 'L- GREASETRAP TYPE/MFG CAPACITY_______ gal #OF COMPARTMENTS A DISTANCE TO NEAREST: WELL _�_ it FOUNDATION-__ _'L'_ it PROPERTY LINE -it ❑ LIFT STATION SIZE _. TYPE OF PUMP._____ O PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES 1, LEACHING CHAMBERSIt OF LINES LENGTH OF LINES it DIS TANCE TO NEAREST WELL, it FOUNDATION _It PROPERTY LINE ft ❑ FILTER BED WIDTH_______ it LENGTH _ft DEPTH -_ _. it DISTANCE TO NEAREST WELL _ _-_ it FOUNDATION it PROPERTY LINE it ❑ MOUNDED WIDTH_ __-ft LENGTH___. ft DEPTH._ it DISTANCE TO NEAREST WELL---- it FOUNDATION _it PROPERTY LINE it ❑ SUMPS WIDTH_ v_It LENGTH____ __- it DEPTH it DISTANCE TO NEAREST WELL, _._— it FOUNDATION if PROPERTY LINE ._ It ❑ DISPOSAL PONDS WIDTH it LENGTH ft DEPTH _ it DISTANCE TO NEAREST WELL_._._____ It FOUNDATION ft PROPERTY LINE- It ❑ SEEPAGE PITS NUMBER _ WIDTH �ft DEPTH ft DISTANCE TO NEAREST WELL _ _ it FOUNDATION _ it PROPERTY UNE it 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. MIN 24 H R A ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-77697 SIGNED _ TITLE _ __.._ DATE IL I J A 1 O E A T DEPARTMENT USE NLY Application Accep __ _cam/ DateZ (_�_ Area 01 =fyq -- Employee ID# ^`Aqg?!i� Final Inspection By - --- 2 � Date. _ S 11 SPECIAL PERMIT-Approved by -- Character of Sol l to th o13 Ft:_._ __ Pit/Sump Soil Character: COMMENTS PE SC Reeelved hec Amount Pe two Date Invoice# Permit 10# Code INFO B RemittalServiee Request# 42-0I ONSITE WASTEWATER TRTMNT SYSTEM PERMIT A04119