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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 -REFUND BLE PE M T CALL I 9 953_-7697 INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS • _ _. _._ ....- ..CRV/ZIP CROSS STREET $_[] l'\ _ APN _ _O �� PARCEL SIZE OWNER NAME_ ` ADDRESS ` _ .__,. `_rte_`._ITS- OWNER CITY/STATEJZIP _ _59+17 CONTRACTOR Y-, _ _ _ _ PHONE __ _ 960 - qqq _._. - CONTRACTOR ADDRESS _._ N ._ _ CrrY/STATE/ZJP �_ LICENSE P-42 I C-36 OTHER _ NUMBER _ _�_ EXPIRATION DATE�� WATER TABLE DEPTH` it GEOGRAPHICAL INFOR TIoN: Coordinates X _ Y PERC TEST N BUILDING PERMIT # __ ___. LAND USE APPLICATION TYPE OF WORK: NEW INSTALLATION RE Am/ADDITION ENGINEER DESIGNED//ALTERNATIVE REPLACEMENT _ LC�Q-�, 0 -OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER_ NUMBER OF LIVING UNITS: NUMBER OF BE ROOMS:NUMBER OF EMPLOYEES: g SEPTIC TANK TYPE/MFG _ CAPACITY gal # OF COMPARTMENTS__ ❑ GREASE TRAP TYPEIMFG _ CAPACITY - _ gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL / It FOUNDATION ft PROPERTY LINE _ It ❑ LIFT STATION SIZE _ _ TYPE OF PUMP___. ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS 0OFLINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL _ It FOUNDATION __ ft PROPERTY LINE It ❑ FILTER BED WIDTH it LENGTH _ _ft DEPTH _ _ It DISTANCE TO NEAREST WELL FOUNDATION ft PROPERTY LINE _ it ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL _ _ FOUNDATION R PROPERTY LINE =1JZ. it ❑ SUMPS WIDTH _ ___ ft LENGTH __ ft DEPTH ~�e 1 ft DISTANCE TO NEAREST WELL ft NDATION It PROPERTY LINES It ❑ DISPOSAL PONDS WIDTH — _ -_ _ ft LE _ ft DEPTH G'tiV i O 9A►� _ It DISTANCE TO NEAREST WELL_ _ it FOUNDATION 1t PROPERTY 1 it ❑ SEEPAGE PITS NUMBER______ WIDTH ft DEPTH_EIN CM Q� UNTV it 'OtjDISTANCE TO NEAREST WELL_ FOUNDATION _it PROPERTYLI LTHD e; EL it I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION A D THE RK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RUL S A ULATIONS OF SAN JOAQUIN COUNTY. M 24 O O CE 1 1 FOR ! P CTION - ASE CALL 209 953-7697 ► 1 If1 t -T7 SIGN Application Accepted By Final Inspection By r:h.—ta, n} zmi m n..th n! 7 Ft - DATE E P ART ME EIO N Y Q/ Date Area' L Employee IDNT� Date_ _ I 1 SPECIAL PERMIT - Approved by PifIR, m Soil Character - V, PESC Received Amount Date PermW Invoice M Permit IDN -CodeINFO ash lRemiltiLdServicee/Reg uest N 0 1 &U /yj I U q 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12