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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-KEFUNDABLE PERMIT CALL (LUY) 9t)J-1W91 FOR INSPECTIONS LXPIRES 'I YEAR FROM UATE ISSUEI JOB ADDRESS 11 / i1 ��" # OF LINES / /W-? DISTANCE TO NEAREST WELL jCITY/zIII�P —Z-0 ft CROSS STREET APN j� (J % /'� PARCEL SIZE OWNER NAME l� L �d"� ` �� /S� Cy�L� / ` c PHONE OWNER ADDRESS Z - CITY/STATE/ZIP ft CONTRACTOR ,per /'t,t.'��Al'1"$'��` //�L PHONE 3 � G6 C' CONTRACTOR ADDRESS O /� �� CITY/STATE/ZIP /V �� /' _/�� DISTANCE TO NEAREST s � LICENSE [1[7,C-42❑CIC-36 C .2 OTHER NUMBER Ex EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION F] REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE C REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM Ei DESTRUCTION INSTALLATION WILL SERVE: El RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ LEACH LINES ❑ LEACHING CHAMBERS Received B Check#/ Cash # OF LINES Date DISTANCE TO NEAREST WELL Permit ID# ft FOUNDATION ❑ FILTER BED WIDTH ft LENGTH S (�J 8 y3 �I °I DISTANCE TO NEAREST WELL ft FOUNDATION ❑ MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION ❑ DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SEEPAGE PITS NUMBER WIDTH DISTANCE TO NEAREST WELL ft FOUNDATION gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft LENGTH OF LINES ft ft PROPERTY LINE ft ft DEPTH ft ft PROPERTY L*E j�ft ft DEPTH 4jpAj-r ft ft PROPERTY LIN ft ft DEPTH CU ft ft PROPERTY LIN 2no ft ft DEPTH SAN ft ft PROPERTjyV/RnA�.IV . COUN ft ft DEPTH OEPARTn4., ft ft PROPERTY LINE ft 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. Vi SIGNED Application Accepted By ` 1 Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS DATE TMENT USE ONLY /( Date 04 3,z "( Area Employee ID# Date ilk I V 1 7I ❑ SPECIAL PERMIT -Approved by Pit/SumD'Soil Character PE Code SC INFO Received B Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# o T5 CK ► Z I� I� 2 S (�J 8 y3 �I °I 4 C �-t' 4' 1331" 79� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/114/ 18 T