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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 9/5,3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Jos ADDRESS �3�i�s+ ��{� ae'`c— �cJ __.._.CITYIZIP Y4jt"o, e,,fr.A f �—r�' 47,S 7�3� ; CROSS STREET APN acy� _ PARCEL SIZE OWNER NaMErrt'A� r� w— jr L L �r G_r�� A C OWNER ADDRESS 7 3� 7 - 4�+, r-' AD CITY/STATE/ZIP�ftt. 1� w:�C✓l+ L CONTRACTOR A�I�C� _ L� -;Caf< �{ T. PHONE �'p CONTRACTOR ADDRESS # [_5r A, CITY/STATE/ZIP I' 1--4 1+eew+ LICENSE 1 C-42 FI C-36 OTHER NUMBER`r1e5_EXPIRATIONDATE�TI� I� WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X �_ Y PERC TEST # BUILDING PERMIT#._ � LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAmIADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION _ INSTALLATION WILL SERVE: L.—RESIDENCE F1 COMMERCIAL [I OTHER NUMBER OF LIVING UNITS: _ NUMBER OF BEDROOMS: _ _ NUMBER OF EMPLOYEES: _ ❑ SEPTIC TANK TYPE/MFG CAPACITY _ . gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG — CAPACITY gal #OF COMPARTMENTS ---- _ DISTANCE TO NEAREST: WELL ft FOUNDATION __ fl PROPERTY LINE _ _ it ❑ LIFT STATION SIZE TYPE:OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) 01 LEACH LINES LEACHING CHAMBERS __ #OF LINES _� LENGTH OF LINES it DISTANCE TO NEAREST WELL A36i ft FOUNDATION f tl t ft PROPERTY LINE_ !fv' ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE it ❑ SUMPS WIDTH __ it LENGTH ft DEPTH it DISTANCE TO NEARCST WELL it FOUNDATION ft PROPERTY LINE ft DISPOSAL PONDS WIDTH ft LENGTH __ ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NuMDER WIDTH ft DEPTH it DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 JOAQUIN COUNTY. MINIMUM 24 HQVQ ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209x953-7697 SIGNED _ _-. TITLE ; f Cs C-- L'a 9r_ DATE :2 a 2i r 71 ON Tj .. t7 t Fn =Zr .._, c EPARTME'NT USE ONLY Application Accepted By. Date Area _.._. Employee 1D# S Final Inspection By _. _ Date ❑ :SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: PiUSunip Sail Character: ._ COMMENTS - -- — PE SC Received Check#/ Amount Permit/Date Invoice# Permit ID# Cade INFO BY Cash Remitted Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4124/12