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`' 1% 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)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM/DATE ISSUED JOB ADDRESS ► CITY/ZIP 41AA/r�,4 ] Q ^ h � CROSS STREET QSG-W t E APN 9 03 U (Day 47 PARCEL SIZE (7 OWNER NAME M.41Vjq PHONE OWNER ADDRESS /�1 S et CITY/STATE/ZIP CONTRACTOR / 4- ��/ PHONE a�O /� � CONTRACTOR ADDRESS f� / I ? CITYISTATE/ZIP IVO E J 9 LICENSE EL-IC-42 ❑IJC-36 OTHER 13 NUMBER -1 ^ EXPIRATION DATE 42 Al do, WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X "�+� Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: C NEW INSTALLATION X REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE D REPLACEMENT I1 OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG E�`-��T\�iGY CAPACITY gal #OFCOMPARTMENTSPf-A _ ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 i SUMPS WIDTH q f ft LENGTH t 0 i ft DEPTH CZ I ft DISTANCE TO NEAREST WELL ft FOUNDATION / V ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION5*11 ft PROPERTY LINE ft ❑ 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. MINIM 4ffA I OURADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 9513-7697 SIGNED O"/ TITLE �WV DATE-44 ly F Q / N M h M 1 DEPARTMENT USE ONLY I Application Accepted By J 1, Date 4), 'o Area 1►�G��P�r^ Employee ID# -SIC. Final Inspection By Date i /LO" ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: r l5ittSump Soil Character: COMMENTS F-cA, vye 6f Ilhes, (',;jv V/GIVCy- feteiyer -)rop ok pe-r -TW. PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO Ca Remitted Service Request# yaio lis t -"300 42V 2 42-01 /7n // I/ ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14118