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` ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL(209)9_53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS j,+% /let J1 CITY/ZIP'j&'1 #-'zx le,'+ 75 33:) Z �]Al OI�I , i Z�7- — D l CROSS STREET yAPN PARCEL SIZE p 0 -- rr � OWNER NAMET�f/ fl'i � �C �t [ � PHONE OWNER ADDRESS Mlt/nK t/Cir k e--A CITY/STATE/ZIP CONTRACTOR P! 1� �� I.°1 ��'� C. PHONE CONTRACTOR ADDRESS Q/r } (�l� S:a CITY/STATE/ZIP LICENSE ❑0C-42 ❑0C-36 OTHER NUMBER O. EXPIRATION DATE `n;17� hn J WATER TABLE DEPTH:NO �::aO ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # I I BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION U ENGINEER DESIGNED/ALTERNATIVE 0 REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM CI DESTRUCTION INSTALLATION WILL SERVE: '❑ ESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS`5 NUMBER OF EMPLOYEES: Ci SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS Cc GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE It U LIFT STATION SIZE TYPE OF PUMP Q PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑I LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE__ ft FIL V TER BED WIDTH 1n t ft LENGTH J. f L1 ft DEPTH 181'1 ft DISTANCE TO NEAREST WELL ft FOUNDATION I-+�j ft PROPERTY LINE_ ft MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE__ _ ft 13 SUMPS WIDTH ft LENGTH ft DEPTH D ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEfi 0 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH tiI t DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE f ft l� SEEPAGE PITS NUMBER WIDTH ft DEPTH .law._ / 7nfn ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI A(I�I� ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQU11- �� r� �t1CTBs, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. 'qR T MINIMUN 48 HOLIA ADVANCE NOTICE-REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE � CG 6MC DATE EPARTME SE N L Y Application Accepte y Date Area Employee ID#71 �� Final Inspection By Date 8 2vz� 11SPECIAL PERMIT-Approved by Character of Soil to Depth of Ft: Pit/Sump Soil Character: COMMENTS � � , (jAe02Af!/(Aj9 Jon�o3 - PE SC Received ec Amount Permit/ Code INFO B ash Remitted Date Service Request# Invoice# Permit ID# ? o io-Z(')ot -- 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/1,@