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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL TH DEPARTMENT 1868 E.HAZEL TON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT /CALL(209)953-7697FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS-r it ' CIT'21P s , --- Rf -_� 7 q CROSS STREET --- APN D S Al ZOO 3 1 _PARCEL SIZE L7. 1, �— y OWNER NAME 061le, PHONE : OWNER ADDRESS _ _ CITYi STATE/ZIP CONTRACTOR s�'G•�4•�'!^ ��J Jam.` PHONE_ `7 rill—lsLDY7 �, 'S/15;-- LICENSE y� CONTRACTOR ADDRESS t�^ ? Lr c�• _ q CITY/STATFJZIP .! 70C��/./S 7;-c„/� LICENSE ,rC-42 .C-36 OTHER -. -__ NUMBER�V� EXPIRATION DATE WATER TABLE DEPTH: _ - _ it GEOGRAPHICAL INFORMATION: Coordinates X Y �PERC TEST # BUILDING PERMIT# LAND USE APPLICATION TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT _ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL W-OTHER 1 ! NUMBER OF LIVING UMTS:-____ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: 7961 SEPTIC TANK TYPElMFG .._ __�f L _ CAPACITY �C/ gal A OF COMPARTMEMS--7--- _ ❑ GREASE TRAP TyPriNlFr, _ CAPACITY_ gal N OF COMPARTMENTS_ i DLSTANCE TO NEAREST: WELL �.-1 K FOUNDATION h PROPERTY LINE _ _ ti ❑ LIFT STATION SIZE TYPE OF PUMP __. O PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS _ YOFLMES____ LENGTHOFUNES — M DISTANCE TO NEAREST WELL __ It FOUNDATION it PROPERTYLINE _ _ f1 ❑ FILTER BED WIDTH it LENGTH It DEPTH it DISTANCE TO NEAREST WELL_ ft FOU WATION it PROPERTY LINE _ N ❑ MOUNDED WIDTH _ _If LENGTH It DEPTH _ If DISTANCE TO NEAREST WELL_ it FOUNDATION_----ft PROPERTY UNE ❑ SUMPS WIDTH ___fl LENGTH_ _ -. If DEPTH.. _ - _-It DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE - It ❑ DISPOSAL PONDS WIDTH -___-_It LENGTH M DEPTH DISTANCE To NEAREST WELL _ N FOUNDATION It PROPERTY LINE It /1 SEEPAGE PITS NUMBER_ / G/ WIDTH u� -N DEPTH DISTANCE To NEAREST WELL N��O l: FOUNDATION It 4-PROPERTY LINE L,= fl 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. MIN UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 r�< SIGNED — TITLE - - - _.-i DATES .5 44 t A - V � — 1 U16, O O O EPARTMENT VSE 9NLY Application Acc -- Date_-Ill T ( _ Area ��I`J y Employee ID# epted y , Final]nape".. Data III tS )(SPECIAL PERMIT-Approvedby Character of Soil to Deplh of 3 Ft: Pit/Sump Soil Character: - COMMENTS vet � —� awl rl o,' .e •l- r,,, � tr I 'l �-"� .t-' - � PE Sc Raeeived hec Amount Data PermW Invoice# Permit ID# Code INFO By Remitted Service Request# 3 --- Lj' L l�- V twt�i Sr�► L to fou — — M Ft��(k 9 a p „ -- 42-01 ` ONSITE WASTEWATER TRTMNT SYSTEM PERMIT IaI 41124T2 ti �9 al