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IU vu ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468.3420 NON-REFUND LE,PERMIT CALL 09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR F DATE ISSUED Jos ADDRESS'; ��//p �%��'. Ar CITY21P CROSS STREET - APN C,O 7O/O 7 PARCEL SIZE 04:�2 > O o OWNERNAME PHONE /_ to rn OWNER ADDRESS C1Y/STATE21P CONTRACTOR PHONE CONTRACTOR ADDRESS CITYfSTATE/ZIP LICENSE QC-42 QC-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDRION ❑ ENGINEER DESIGNED ALTERNATIVE ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM x DESTRUCTION TG- INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUM BER OF BEDROOMS: NUMBEROF EMPLOYEES: O SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS U GREASE TRAP TYPE/MFG - CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL it FOUNDATION it PROPERTY LINE R \� LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) LI LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LANES 'ft \ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft Q FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE ft O MOUNDED WIDTH ft LENGTH ft DEPTH R DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It O SUMPS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE ft 0 DISPOSAL PONDS WIDTH ft LENGTH It DEPTH DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE 11 SEEPAGE PITS NUMBER WIDTH It DEPTH k DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE R 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. MI IM NF22(4}H R A NCE CE REQUIRED FOR INSP �T -PLEASE CA iL(209)9 697 SIGNED V Y l X X G� TITLE L 2 ! • � j j i i i `t t' I I I 11 I 1 t ..... ..,._ ... ..... ..._ ._...t I ..;.......1... ___..;.......�...... .. .............. 1.......1.......}.......:.......y..... ...�.}-..«.1.....; jt .. m .'1 i i i 1 i IiEC41VE$1 i i f .._......I.._.. .....' ..�...... +_ j.�� . .....�.....ti�....... i I ...;.......j........;.......�I.......:I.. L--. ..1.......t......T..............:... ..« SAgU"ONY -iL; •.•.. .. HEA4THDET1 NT L ..................... .. _...... _ I ,,'+ ....... ......f Jj��..M�111�. ..;......i.......i ...i....... i... ... i.......;.... .. .... ......L......L......a..._..i.......... ... ..i.......t. .. .. ....1.......�...... .......i.......1. .. _ .. .. .. r...». ._«�. j........... ....j.......r.. ..r.. ..{.. ^.EFA•RI=VA_EI:I�iy�U Area d� �'�`�j Appllcatlon Ac Date i/ Employee ID# -T��Y Final Inspection Date ze" 11/1 U SPECIAL PERMIT-Approved by �, Character of Soil to pth of 3 Ft: PiVSump Soil Character: COMMENTS 4lc CGr7 � GJlie/ l ` � Q _ PE Sc Received Cbegw Amount Date Permit/ Invoice# PermitID# Code INFO B a emitted Service Ftuest# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 8/26!09