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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-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS , EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS K a `T % C %TCA-N7%/�4\- _ # OF LINES I- _ _ CITY//ZIP 11 �;K V 7 l/G� CRdSS STREET r WELL__ ft .^ FOUNDATION�V' APN 0 I % - Z ` o ^ 3 r PARCEL SIZE OWNER NAME D�r�Ci � a � DEPTH ft q0^( PHONE Z6 [ - 6 3'/ r`p�rT OWNER ADDRESS 7C�7/ GQ1"'' O CITY/STATE/ZIP 46CC""P GA- 4PS-ZZt WIDTH ft LENGTH ft CONTRACTOR L� DISTANCE TO NEAREST PHONE FOUNDATION CONTRACTOR ADDRESS LICENSE ❑ C-42 ❑ C-36 OTHER NUMBER CITY/STATER EXPIRATIONd1AT& __ f► WATER TABLE DEPTH: -7o ft GEOGRAPHICAL INFORMATION: Coordinates X 'W U PERC TEST # BUILDING PERMIT #. LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM x DESTRUCTION INSTALLATION WILL SERVE: A RESIDENCE IJ COMMERCIAL A I I OTHER NUMBER OF LIVING UNITS: ?,Am UA4,r NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: I SEPTIC TANK TYPE/MFG ✓tri'G/ CAPACITY 1Znf% gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG _ CAPACITY c gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION 7 t ft PROPERTY LINE ZO f It ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS _ # OF LINES I- _ LENGTH OF LINES Q'� ft Amount Remitted DISTANCE TO NEAREST r WELL__ ft .^ FOUNDATION�V' ft PROPERTY LINE S ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION _ ft PROPERTY LINE _ ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It 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 l�iQ� ft FOUNDATION -ft PROPERTY LINE I ft 1 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. MINIMM 24 Ha4ffl A QVAWE NOY ICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED _ TITLEX D t -IJ A.t-l-i DATEx ,�� Application AcceptedAL— Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTStXD Lnr I DEPARTM Date Date Area l�. ❑ SPE Pit/Sump Soil Character: L L Employee ID#65—��-o AL PERMIT - Approved by PE Code SC INFO Received BV ck#/ I Cas Amount Remitted Date Permit/ Service Request # rmit ID# VwV-%fFT 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12