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I ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE -STOCKTON CA 95205 -(209) 468-3420 NON-KEFUNDABLE PERMIT L:ALL (ZUY) Yb3-11iy/ FOR INSPECTIONS LXPIRES�y1 YEAR FROM DATE ISSUE JOB ADDRESS l 1 to jr nwV ) Z CITY/ZIP C C "l 1 S 2 'l o WELL ft 00 C. CROSS STREET /�f y7y�l /1 l/l�,[ APN / / V PARCEL SIZE OWNER NAME Lr��% /s (ilelrl< DEPTH ft PHONE CL' '-n 4y 1 7SLt� OWNER ADDRESS y�l Ty &5 r 14.,i 12- CITY/STATE/ZIP c, A CONTRACTOR A r 1� �r`,Y(l\^ /'i%1l 1r1/t�N M044Ni1dd (�L , �'V'V.l P5 T►�PHONE Z,Z1 I " P77 4��`j CONTRACTOR ADDRESS 4 7 I IC. h T P -r 1A �r j z e 1.JA_Sj `,u �ZrG �� CITY/STATE/ZIP p PCi CSP'/C4 [ 5' 3 %JR LICENSE ❑ OC -42 ❑ CIC -36 OTHER P t✓ NUMBER S ✓ S EXPIRATION DATE Or % /� / WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y A 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 ❑ 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 gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS Received By Check#/ Cash # OF LINES Date LENGTH OF LINES ft Invoice # DISTANCE TO NEAREST WELL ft FOUNDATION C. ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft 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 THAT I HAVE PREPARE" iIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STAIE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. IV/NVNVIVIVI -to v n My/L-F IVU"S'S r[C u"N'rvr[ I/var"I lvrvo - 1 cva .7JJ-/UJ/ SIGNEDTITLE 110A40DATE �3)2-1 RTMENT VSE ONLY Application Accepted By Date \ Area Employee ID# Final Inspection By t/ o Date ID t ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth o 3 F : Pit/Sump Soil Character: COMMENTS PE Code SC INFO Received By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# ' C. IZ 3 Z( i2 �o$�15u 3 42-01 6W,�f /�� % ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/16 /