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L ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT S® ¢ C' JOB ADDRESS f IT t YbJ-1b,9[ FOR INSPECTIONS f tXPIRES "I TEAR I -ROM LIATE 155UEI CROSS STREET PC [ / APN ( Y -t - !ZO PARCEL SIZE 61 a OWNER NAME \ , l i fi ; vii I _ itCi /0 j'-- G �/ PHONEZ�� 7- 5175 OWNER ADDRESS S�L/ �f I' L/�yg— 11061106S12 l � LS CITY/STATE/ZIP S'{E3C 6�ZU1^ % ---44 '-InS_:.7/Z CONTRACTOR 92(/Tl 6'E9'5- PHONE /�� % 7 11c�U 7 7("'? CONTRACTOR ADDRESS /(7 �C///??/iii/i f'L�li z4, CITY/STATE/ZIP �fGC�G D!/L (9 A `f /� S;xc 7 LICENSE 1111C-4211013-36 OTHER r� g ( NUMBER W67e--EXPIRATION DATE Lf �:o -.HOZ 1 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ ,PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESI( REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM ?9:1 DESTRUCTION NED INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFTSTATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP LEACH LINES - LEACHING CHAMBERS ft FOUNDATION Permit/ Invoice # Permit ID# Service Request # DISTANCE TO NEAREST WELL ft FOUNDATION FILTER BED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL SEEPAGE PITS NUMBER WIDTH _ DISTANCE TO NEAREST WELL CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT G gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES LENGTH OF LINES ft FOUNDATION ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE 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. MINIMUM4B HO DV NCE NOTICE RE UIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 SIGNED TITLE g,) S;ri 'SS DATE / // Z/79 z DEPARTMENT USE ONLY /� Application AcceptAepth Date 1 /e"1 .'! Area -1 1 Employee ID# ^s Final Inspection By Date F -SPECIAL PERMIT - Approved by Character of Soil to of 3 F . Pit/Sump Soil Character: COMMENTS LacuJ for bf sgp}ii- u ok,"vin _ /\J Iv on rile, S -e2 PE SC R eived Code INFO B ft ft FOUNDATION Permit/ Invoice # Permit ID# Service Request # 1 o -?S ft ft FOUNDATION 03qne ft ft FOUNDATION ft ft FOUNDATION ft ft FOUNDATION ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE 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. MINIMUM4B HO DV NCE NOTICE RE UIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 SIGNED TITLE g,) S;ri 'SS DATE / // Z/79 z DEPARTMENT USE ONLY /� Application AcceptAepth Date 1 /e"1 .'! Area -1 1 Employee ID# ^s Final Inspection By Date F -SPECIAL PERMIT - Approved by Character of Soil to of 3 F . Pit/Sump Soil Character: COMMENTS LacuJ for bf sgp}ii- u ok,"vin _ /\J Iv on rile, S -e2 PE SC R eived Code INFO B eck Amount Remitted Date Permit/ Invoice # Permit ID# Service Request # 1 o -?S 61S 03qne 42-01 4/14/16 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT T