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T -"-AA 5(" �J-1--16 07 - 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 2 9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM UATE ISSUEI JOB ADDRESS Al `? �',� ��j Q� /� Q CITY/ZIP i '� �,Vp44MLQ4�6�iZ7 CROSSSTREET �! 31 ]7 APN l/ 0 -1 `Sr S—PARCEL SIZE 6(� OWNER NAME -7 I PHONE n ' LL/��- %7 G 7��J OWNER ADDRESS Z) CITY/STATE/ZIP CONTRACTOR C I.LMj--e' &Z � PHONE CONTRACTOR ADDRESS LICENSE ❑ C-42 ❑ IJC-36 OTHER CITY/STATE/ZIP NUMBER EXPIRATION 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 ED /ALTERNATIV REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM x DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE LI COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STAT TYPE/MFG TYPE/MFG 01'rANCE TO NEAREST: WELL TYPE OF PUMP CAPACITY CAPACITY It FOUNDATION ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OFC ARTMENTS ft PROP TY Z )k .' ft R(Meweraill ❑ SAND OIL SEPA0*T" ❑ LE INF&ACHING CHAMBERS DISTANCE TO NEAREST WELL ft # of LINES FOUNDATION LENGTH OF LINES ft ft PROPERTY LINE bA ft ❑ FILL ED WIDTH ft LENGTH INFO ft DEPTH Cas Remitted DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE lilt-, il1 ❑ MOUNDED WIDTH ft LENGTH I JL JL.:djNl ft DEPTH (/G A „_ DISTANCE TO NEAREST WELL ft FOUNDATION c�(ftJ ft PROPERTY LINM� 64 ❑ SUMPS WIDTH DISTANCE TO NEAREST ft LENGTH WELL It FOUNDATION �q� ft DEPTH �� FN`V��jHH� UIN (- „-ft7�I ft PROPERTY LINE � ��141 ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH MENiI DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY T,1If4T I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, n STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. SIGNED DATE II ' ' ' " 'Illllllllllllll DEPARTMEN EO LY Application Accepted B Date z li Area Employee ID# �d Final Inspection By Date ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS- PE SC ReceivedChec Amount Permit/Code INFO B Cas Remitted Date Service Request # Permit ID# �S I JL JL.:djNl 111.Fv --- ii 1jLj.;d" 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12