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ONSITE WASTEWATER o Rcf„'!0FNT SYSTEM PERMIT SAN JOAUUIN COUNTY ENVIRONMENTAL HEAL I H DEPARTMENT 1868 E. HAtrLTON AVENUE-STOCKTON CA 95205- (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE' SSUED JOB ADDRESS _._ _CITYIZIP CROSS STREET _ _ APN _ _-_ PARCEL SIZE OWNER NAME_ ,r> A•*)�.: �i ?.� PHONE, OWNERADDRESS ,.1 i 1 1: I —_ _ ` _moi}_CITYISTATE/ZIP I, - CONTRACTOR ll3 `�+i•..r i 4�� ( PHONE a'� f-� (ti l •; I' _ CONTRACTOR ADDRESS •'1.iA. _i�.. — F�,.i S,,L_} �,J-i CITY/STATE21P LICENSE ?. C42 ❑ IC -36 OTHER__... 71 _.. _. _. ..__ NUMBERS__ EXPIRATION DATE ! r WATER TABLE DEPTH: _ it GEOGRAPHICAL INFORMATION: Coordinates X Y_ ❑ PERC TEST r BUILDING PERMIT # _ LAND USE APPLICATION # _ TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE it FOUNDATION REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: Gi RESIDENCE LJ COMMERCIAL ,4, J OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: _.__. ZLI NUMBER OF EMPLOYEES: _ it DEPTH it DISTANCE TO NEAREST WELL H FOUNDATION h PROPERTY LIN _ It ❑ SEPTIC TANK TYPE/MFG _ CAPACITY 1C`r-i�.-' gal # OF COMPARTMENTS O GREASE TRAP TYPUMFG - CAPACITY gal # OF COMPARTMENTS ft DEPTHNag I ft DISTANCE TO NEAREST: WELL _. it FOUNDATION It PROPERTYLINE it ❑ 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 it FOUNDATION--- --it PROPERTY LINE it ❑ FILTER BED WIDTH ___ __ N LENGTH it DEPTH It DISTANCE TO NEAREST WELL it FOUNDATION R PROPERTY UNE _ ft ❑ MOUNDED WIDTH it LENGTH it DEPTH PA v. _ ft DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE -'” it ❑ SUMPS WIDTH it LENGTH it DEPTH it DISTANCE TO NEAREST WELL H FOUNDATION h PROPERTY LIN _ It ❑ DISPOSAL PONDS WIDTH it, LENGTH It DEPTH 4sw — Oi%_ ft —A��_ DISTANCE TO NEAREST WELL -� it FOUNDATIONfi PROPER QVA_ / _ ft ��—"r ❑ SEEPAGE PITS NUMBER _ WIDTH ft DEPTHNag I ft DISTANCE TO NEAREST WELL K FOUNDATION _ it PROPERTY LINE FA�n� it 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 JOAOUIN COUNTY. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)_ 953-7697 SIGNED TITLE DATE Application Accepted By Final Inspection By __ _ Character of Soil to Depth of 3 Ft: COMMENTS DEPARTMENT USE ONLY Date�_ _ Area EmployeelDn____„_ Date _ SPECIAL PERMIT • Approved by Pit/Sump Soil Character: U A1C PE SC Received Check$/ Amount Date PermW Invoice # Permit IDI Code INFO B Cash Remitted Service Request 0 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4(2.7112 V.