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t t ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT �L ' CALL 209 953-7697 FOR INSPECTIONS n �r_y�rEXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 16 1 01 VV -(4 IZA-t--I / U C-4 f' 'J CITY/ZIP ' 1` _1 . TS 2 y X3_1 ko 57 APN �� a CROSS STREET �/-,1 'n .- c /�,1 1 y�1 T\1 ,I 4f4 ��.p� L�V� /I�O ,JI� � PARCEL SIZE d OWNER NAME `� � ktl V 3�'-Ir ` `n�1�0 4 1\,r►rIv 7 r, D'R'^�V►�lj I NIC PHONE /� � OWNER ADDRESS k:2�(�11 VV `C1/`'r'_'"r f ►^J IVE CITY/STATE/ZIP 'j1' /��(TC�A CONTRACTOR �' T�� 1 � VVG� �J / PHONE (66 � Zt� I �l CONTRACTOR ADDRESS l 6 O I pj-x W ✓!1 yl� /`Gl CITY/STATE/ZIP ( 5S�200fCA 3 e LICENSE 1111C-42 110C-36 OTHER NUMBER [ Ci fl� EXPIRATION DATE V .7 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT LAND USE APPLICATION## TYPE OF WORK: ❑ NEW INSTALLATION REPAI DDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER 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 ft PROPERTY LINE ft C LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) C LEACHING CHAMBERS #OF ES LENGTH OF LINES ft ISTANCE TO NEAREST WELL FOUNDATION ft PROPERTY LINE ft / DTH ft H ft DEPTH ft DIS NCE TO NEARE WELL ft FOUNDATION ft PROPERTY LINE ft NDED WID H ft LENGTH ft DEPTH ft NCE TO NEAR ft PROPERTY LINE ft ID H V ft LENGTH H ft DIST NCE TO N ft FOUNDATION ft PR TY-L-IN ft ❑ WI H ft LENGTH ft DEPTH ft �-- DIS ANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS Nu BER WIDTH ft DEPTH ft DIS ANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVPREPARED 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. 4 MINIMUM 1 HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE DATE zo F� A _ EAT D P RT E T 0 ARTME T U E Y Application Accepted By Date Area Employee ID# Final Inspection By 1l �.. Date ❑ SPECIALFEMIT-Approved by Character of Soil to pth of 3 Ft: Pit/S mp S it Character: COMMENTS f "/'t�14 D ah D C �oDg -9L Crx .I- ll. 6 W eor d PE SC Received hec Amount Date Permit/ Invoice# Permit ID# Code INFO ash Remitted Service Request# 3 S o 10 31 Q Cl 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12