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ONSITE WASTEWATEA'tREATMENT SYSTEM PERMIT JOAJUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZEL10rl AVENUE-STOCKTON CA 95205-(209)468-3420 _NON-REFUNDABLE PERMIT - CALL 2091 953-7697 FOR INSPECTIONS E XPIR ES 1QYEAR FROM DATE ISSUED � JOB ADDRESS l �t v -- -- -- j J_CIT{{YIZIP CROSS STREET� Ll / APN�'! �� _1l I L 1 PARCEL SIZE �✓L 3 C7 OWNER NAMPHONE r '. OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR PHONE GxiG PHONE CONTRACTOR ADDRESS �� 2 -_ CITY/STATE/ZIP LICENSE X C-42 nl,C-36 OTHER NUMBEROr/ EXPIRATION DATE I - 1 WATER TABLE DEPTH:I I-z L) _ ft GEOGRAPHICAL INFORMATION: Coordinates X _ _ Y 'TEST # —1 BUILDING PERMIT# _LAND USE APPLICATION# -- -1 TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:^ '-'L El -- -- --- ---------//__ �- SEPTIC TANK TYPE/MF(l CAPACITY V gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY _- gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL 0>` It FOUNDATION /O!4 It PROPFRTY LINE L) L� LIFT STATION SIZE L " H TYPE OF PUMP—____ ❑ /PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) C�{.(/�'i 'Y.(,- 71 Wm-�II�*v-1--A L'R t; __�,�I S U/�L- W - I LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES S d ft DISTANCE TO NEAREST WELL J It FOUNDATION__. —/6A -It PROPERTY LINE j 'j It ❑ FILTER BED WIDTH It LENGTH _ft DEPTH- It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH It LENGTH _ _ft DEPTH It DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SUMPS WIDTH -_ It LENGTH — _._ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION —_ ft PROPERTY LINE _ It ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS Nun+BER_ /�(. WIDTH It DEPTH S It DISTANCE TO NEAREST WELL It FOUNDATION _ z PROPERTY LINE 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. MINIMUM 24 HOUR AAVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED TITLE (-,[ DATE L i i r ni�U N :':)J`I(Y _ DEPARTMENT USE ONLY Application Ac.ep�d trate 4- : G�'� Y V,-6C _— ht�.: L-:nplC H,!ILAI Final Inspection }rB L , L'G! _ 'f Date_JL/4,111 _._ ___ SPECIAL PERMIT-Approved by Character of Soil to De th of 3 Ft: Pit/Sump Soil Character: COMMENTS l'' 1 > T -r- s-rg4p/3 111 fE PE SC Received Check#/ Amount Permit/ Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# K%_ :��'�l•, _�'�---� -- � G cwt L - s�'+TQC,� � :, ,tiL, � C J � .��%LI, !J-f""lam � C , c� �• � �� :I�-��9 � -G L'lc: 744 L-TL 42-01 � hal Ir-v ZlC//j�j ONSITE WASTFWATER TRTMNT SYSTEM PERMIT t