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r ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 9868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT / CALL209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1172- 12- �/T/� �✓fLL' CROSS STREET ,a1(Y�rV7_ RD�� ApND�p- Z©D ' y Z PARCEL SIZE -//. 2�C 'a OWNER NAME -Tell"A)/FC-?C, D HONE OWNER ADDRESS O G � T6OCt I—kJCITY/STATE/ZIP 51- lu(T 1(/1�f1°V1C®y5GC/ L S CfJ CONTRACTOR &_-t t SIL41711 PHONE 2- ,�— 2 CONTRACTOR ADDRESS 090 COW64 CITY/STATE/ZIP 51%"vLICENSE 1 C-42 1A C-36 OTHER 9 - 2NUMBERf2_3 i�16 EXPIRATION DATE 149- Z02-1 I WATER TABLE DEPTH: I [)��' l I it GEOGRAPHICAL INFORMATION: Coordinates X ,3,/ (I PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM X DESTRUCTION INSTALLATION WILLISERVE: y � RESIDENCE i� COMMERCIAL L^, L_l OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: & S NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG ` `� CAPACITY ©0 gal #OF COMPARTMENTS 3 ❑ GREASE TRAP TYPE/MFG CAPACITY // gal #OF COMPARTMENTS L DISTANCE TO NEAREST: WELL .300 ' It FOUNDATION b 0 , ft PROPERTY LINE 15-1 2 ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS z y X�8 #OF LINES / LENGTH OF LINES 60 ft DISTANCE TO NEAREST WELL 300 ft FOUNDATION f0 ft PROPERTY LINE 15 r ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAR/EST WELL p ft FOUNDATION ft PROPERTY-LINE ft 6 SEEPAGE PITS NUMBER WIDTH 11 P/5" / ft DEPTH 2 7 / ft DISTANCE TO NEAREST WELL 300 r ft FOUNDATION ft PROPERTY LINE 15 ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE Willi SAN JOAQUIN COUNTY ORDINANCES, S TE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIM 4 HDU AD N NOTICE REQUIRED FOR INS/PyEICTIONS,p- PLEASE CALL 209 953-7697 p SIGNED 1,5 TITLE / /ye;�'Vwm_ DATE - r X 7- fC ld uC! S; T T D © t" 9 \ J A UItN TYN E T rr D6.P TM ENT ON Y Application Accepted B to l Area Employee ID# Z� Final Inspection By Date M If El SPEC=W0 IT-Approved by Character of Soil to Depth of 3 Ft: t; Pit/Sump Soil Character: COA70f j, COMMENTSj_L-C-_ __11L (-.)A StrreW4r24 WTzgAJ 7Tdf* a PE SC Received Check#I Amount Permit! Code INFO B as Remitted Date Service Request # Invoice# Permit ID# a S0 I 1 �,�Iri-�.� tip.-r� d�..;.! �Ee ✓r-c L�l wa S, �K''�� d�� LCL LAS. 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4114118