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1A1- n 5 ONSITE WASTEWATER TREA-riviENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT COLL 209 953-7697FORlNSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS _ _�7y_'Crry/z/zlp CROSS STREET J>' /� � ,(A Imo'N �✓ YJV a�PARCEL 'SI�ZE �[ _ OWNER NAME-_��e+'^ �F%7;=/ v _I/VL PHONEf"""'�/ j�"� �� v OWNER ADDRESS�� 3�3� L CITY/STATE/ZIP/�7�,_ CONTRACTOR rJ/� �j��f�� 1�1'r/�r ' , - — PHONE��.}.[_ya�1 CONTRACTOR ADDRESS -2 --G---/�Y ��_/nj___.___ _ _ ._..CI'Y/STATE/ZIP' LICENSE X C-42 H. C-36 OTHER NUMBER O EXPIRATION DATE_— WATER TABLE DEPTH: 21 u._�___.ft GEOGRAPHICAL INFORMATION: Coordinates X _ Y Ll PERCTEST #_ BUILDING PERMIT#-_-_.-. . —LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE �Z— REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM X DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE Ae—COMMERCIAL L] OTHER--. _. . NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:_._- _ NUMBER OF EMPLOYEES: / SEPTIC TANK TYPE/MFG __ _— CAPACITY D D gal #OF COMPARTMENTS ❑ GREASE TRAP TYPr/MFG _ CAPACITY_ gal #OF COMPARTMENTS r DISTANCE TO NEAREST: WELL _._,?..,(L ft F(NIHDATION_� it PROPERTY LINE J ,� it ❑ LIFT STATION SIZE _ TYPE OF PUMP___- _ O PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS It of LINES_ / — LENGTH OF LINES N DISTANCE TO NEAREST WELL�.2� it FOUNDATION�� t,- R PROPERTY LINE If ❑ FILTER BED WIDTH _ __—it LENGTH_ ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION it PROPERTY LINE It ❑ MOUNDED WIDTH _. -- _--_Il LENGTH _.—_ R DEPTH it 11 DISTANCE TO NEAREST WELL O FOUNDAIITNI it PROPERTY LINE fl �i—SUMPS ?i WIDTH 'Z It LENGTH__- _ ft DEPTH —�� It 11 DISTANCE TO NEAREST WELL It FOIINDAT ION yj�j�it PROPERTY LINE—,1 It ❑ DISPOSAL PONDS WIDTH_—_- ____It LENGTH it DEPTH it DISTANCETO NEAREST WELL _- It FOUNDATION _—___II PROPERTY LINE B ❑ SEEPAGE PITS NUMBER__—_ WIDTH__—, ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDAI ION fl PROPERTY LINE it I I IEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITI1 SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUM 24 HOURADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED _ ___ TITLE_GL�I� _.._ DATE Nil 1 19 -- - - EPIARTMENT USE O ��" Appiic ion Acce — - — Date 7. Area _SLA, Employee ID# Final Inspection By _ Date_ .. �— L7 SPECIAL PERMIT-Approved by Character of Soil to De th of 3 Ft: _ PiUSump Soil Character:—_ COMMENTS •� �1�� 'rL CYJJ 5�3oL�i �b �is7l �!/J icOT PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B Cash Remitted Service Rnuest# 11 -7S� °° 7 ct�OD 7(P 42-01 ONDTE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12