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Znmal Sicto AIl1,llj,wl ONSITE WASTEWATER TREATMENT SYSTEM PERMIT o,jr_.d/a /-.j //f, SAN JOAQUIN COLINIY ENVIRONMENTAL HEALTH DEPARIMEN T 1868 E.HAZE LTON AVENUE-S TUC;KTON CA 95205.j209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953_-_7697 FOR INSPECTIONS EXPIRES 1 YEAR FRO DATE ISSUED JOB ADDRESS 1 00 • Co mQ�� N��c R __ Crryrljp CROSS STREET IN Y/n� IL��_ APN - �J� PARCEL SIZE OWNER NAME A rl!'C`(f1 IV C('n('4� OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR i=AI j k(-L-� SEyv�I C. PHONE CONTRACTOR ADDRESS 1 C, - "IQC(FV q- R(� _. CITY/STATE/ZIP LICENSE C-42 G36 OTNER _._ NUMBER�312 I is EXPIRATION DATE S/: WATERTABLETABLE DEPTH: ry 11_ _ _. _ h GEOGRAPHICAL INFO AT ON: Coordinates X Y PERC TEST tl BUILDING PERMIT# LAND USE APPLICATION If TYPE OF WORK:—� NEW INSTALLATION REPAIRIADDITION ENGINEER DESIGNED IALTERNATIVE �� REPLACEMENT O T-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: I: RESIDENCE COMMERCIAL GD, ❑ OTHER NUMBER OF LIVING UNITS:_- NUMBER OF BEDROOMS:_ - NUMBER OF EMPLOYEES ❑ SEPTIC TANK TYPEIMFG-1--+-� CAPACITY -f l'l' al NOFCOMPARTMENTS-2— ❑ GREASE TRAP TYPEIMFG _ CAPACITY 6 gal N OF COMPARTMENTS__ DISTANCE TO NEAREST: WELL .�G O� H FOUNDATION U If PFOPERTY LINE '1iJ h ❑ LIFT STATION SIZE TYPE OF PUM S 13 PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS NOF LINES LENGTH OF LINES ft AT NCE To��NEAREST WELL 11 (tFNOATION__ I( PROPERTY LINE __ it 21 FILTER BED lbo WIDTH _—L7tcf it LENGTH O fl DEPTH It v DISTANCE TO NEAREST VfELL J(]D(�,1]�O' FOUNDATION yS-C?_ ft PROPERTY LINE ❑ MOUNDED WIDTH h LENGTH--,� ._ft DEPTH it DISTANCE TO NEAREST WELLIT FOUNDATION h PROPERTY LINE N ❑ SUMPS WIDTH h LENGTH IT DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION It 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 AEAREST WELL it FOUNDATION ft PROPERTY LINE_ It I I IEREBY 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 CCUNTY MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED (• �C+l,'.i ' _.. _ TITLE CCS'vljnCT__. _ DATE IO - v I c ` v C r � r DEPAR TMEN TrUSE 0 NL AppucauDn Accepted _ Dale_! ( Area l_ _ Empioyaa IDS Final Inspection By Date _ _, SPECIAL PERMIT-Approved by yr Character of Soil to Depth o(3 Ft: t/Sump Soil Character: COMMENTS ....— PE SC Received Check#/ I Amount =2rmiU Code INFO By Cash i Remitted Date Service Request* Invoice# Permit IDS Lc 77A:0 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24112