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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 yE PERMIT UALL LUYOJ-/O`!/ PUKINSI-LGIIUNS CAVIKtS I TCtAK I-KUIVI UAIt IJJUtI JOB ADDRESS /'')6^- • G��G L5 r Awl--' CITY/ZIP -'NZ-(GC U/ ce )1 J 3o t/ CROSS STREET I� JS`j w-� APN q!30 -?05?— r PARCEL SIZE OWNER NAME 1 Y-'C�V':� n( -I \ /� PHONE C, �7 OWNER ADDRESS ck��.�-Zy A L) t \� L� CITY/STATE/ZIP \� �%� ` � C Oz- CONTRACTOR`S C-PHONE�O CONTRACTOR ADDRESS L I �� CITY/STATE/ZIP 7'�=T C (. 1 LICENSE ❑❑C-42 ❑0C-36 OTHER NUMBER 97 EXPIRATION DATE 1 /30 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION ❑ PERC TEST # BUILDING PERMIT## TYPE OF WORK: NEW INSTALLATION I] REPAIR/AD Coordinates X LAND USE APPLICATION # DITION ❑ ENGINEER D Y ESIGNED /ALTERNAT)VE REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ;Y DESTRUCTION Sf Tl< V-,YI K INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT 7 gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS Cash Amount Remitted # OF LINES Permit/ Service Request # LENGTH OF LINES Permit ID# a � DISTANCE TO NEAREST WELL ft FOUNDATION S (,Y�27 ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE I HEREBY CERTIFY THAT) 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. SIGN Application Accepted Final Inspection By Character of Soil to Depth of 3 COMMENTS Vrx I/YJnrCI. I IWIVO - rLC/`1JC %'FILL I LVzFj .7JJ-/ V.7/ TITLE IDV7r-�04—A— DATE 16--\3� 2c0d 13 DEPARTMENT USE ONLY _ "'4z1Vj" Date/(3/.� Area 5 ra Employee ID# DA Dat ?iTV ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: //I . �... D,/�I �/l ✓-l/a•/i ( � tai/'! , ft ft ft ft ft ft ft ft ft ft ft ft PE Code SC INFO Received By Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# a � o7s ►sa l 013 S (,Y�27 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14118