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ONSITE WASTEWATER TREATIMIET S"AfSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 9868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT/ CALL(209)953-7697r-Oa INSPECTIONS ExPIRES I YEAR FROM DATE_ISSUED JOB ADDRESS �//925V iC11 UE44A en CITY/ZIP 04C&O AD G/a ;, D ty DR PFL7%E o�D APN/1 I � ?7 Z'�' 6 3 cD CROSS STREET ', ^ /� //// PARCEL 517_E s- Y OWNER�!AME 40Y AJ- 6RUEUA �.D PHONgc��/,� ��9 OWN�- -Ss ACITY/STATE/ZIP r- 16 CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE DDC-42 DFIC-36 OTHER NUMBER EXPIRATION DATE !NATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE_OF WORK: I NEW INSTALLATION I_! REPAIRIADDITION U ENGINEER DESIPNED/ALTERNATIVE !_I REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: 1-1 RESIDENCE Fl COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: F-3 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 LIFT STATION! SIZE TYPE OF PUMP 0 PKG TX PLANT Ct SAND OIL SEPARATOR(ENCLOSED SYSTEM) h LEACH LINES 1.1 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELT_ it FOUNDATION it PROPERTY LINE ft G7' FILTER BED WIDTH ft LENGTH it DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft t 5ROU14DED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft r SUMPS WIDTH ft LENGTH it DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft n DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION _ ft PROPERTY LINE ft C] SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 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. loll utvr-4-8-,(0URfiDVANE NOTICE REQUIRED FOR INSPECTIONS•-PLEASE CALL(209)953--7697 SIGNED TITLE DATE t — — -- R — D --- _ �17EPARTNIENT USE O IN(_ Y Application Accepted By ` Date C�- AreaEmployee ID# Final Inspection By , Date 7-r) 0 SPEC AL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS eLt pb!;�.e PE SC Received Check#1 Amount Date Permit/ Invoice IF Permit IDtt Code INF) By 09 Cash Remitted Service 4equost# lit-4- _- VI s" 011. E 4 -p! , O 2 `�a tr'rf^ ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/74/'I8 � U