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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 IVUN-MtI-UN1UA13Lt rhKMI i ALL (LUN) V0J-f0&f FOR INSPECTIONS tXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS Z8,1 �o e1T 1-1 C� S TiktY'S- ' CITY/ZIP TT' C IC ty , J j 2 Iz CROSS STREET `� �' �' ' / � `, APN � � ( I '/ CL,�� PARCEL SIZE ' OWNER NAME t4 OA I Y C,fLL �%LOrIGS `ip' PHONE TO 4bri - -)-)go Q WNER ADDRESS,�7 7- L1 I k /+�2 N � 1 V CITY/STATE/ZIP SnC IL/ty�"s�1 a l A 1 CONTRACTOR 1 A Tti 1ti Coc�►s T HS n� PHONE -2 1-1 —'11 a 17 CONTRACTOR ADDRESS b 2 v Co IYSc S 4w ej CITY/STATE/ZIP CA 9 ` LICENSE ITC -42 [ I C-36 OTHER NUMBER c�n 2 EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1-1 PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM k DESTRUCTION 5t' INSTALLATION WILL SERVE: 11 RESIDENCE I COMMERCIAL 11 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 ❑ LEACH LINES f LEACHING CHAMBERS CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PRO ft ❑ SAND OIL SEP RAT Y M) axTr�_ # of LINES LENGTH OF LINES ft ISTANCE TO NEAREST WELL Received B ft FOUNDATION Date Permit/ Service Request # ft PROPERTY LINE ft ❑ FILTER BED N:IDTH ft LENGTH ft DEPTH ft CE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft El ft LENGTH No ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN ft ❑ WIDTH DISTANCE TO NEAREST ft WELL LENGTH ft g®� DEPTH 9 �7ft ft PROPERTY LIN ft ft FOUNDATION ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST L3 SEEPAGE PITS NUMBER WELL It FOUNDATION ft PROPERTY L aQ1l1N ft ft DEPTH HEAT °'ENTAL ft WIDTH DISTANCE TO NEAREST WELL ft FOUNDATION 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INS'^PECTIONS)- PLEASE CALL 209 953-7697 SIGNED TITLE _I—tGr, r /¢�.�+J t DATE% 7'- I No11111FNIFN� SC INFO Received B Check#/ Cash Amount Remitted Date Permit/ Service Request # rmit ID# v 7 ole z8 ( PF12 F" No ME No No 0 'MEMO i ON No No ME MEMEN 0 ON No 0 No NES ON■ DEPARTMENT N Y Application Accepted By c522��6 Date Area Employee ID# Final Inspection By Date 11 SPEC AL ERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Charac4er: COMMENTS 4UC a", is y, It L.2.e 1s er- jjU Lt PE Code SC INFO Received B Check#/ Cash Amount Remitted Date Permit/ Service Request # rmit ID# v 7 ole z8 ( PF12 F" 42-01 �r`� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12