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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 PER PERC TEST # 2209 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE 155ULL JOB ADDRESS LAND USE APPLICATION # �JCALL C 1. - CROSS STREET REPAIRIADDITION 's/f'2CITY/ZIP APN v / � � ��—PARRCEL SIZE Ai �,/I1//� I Han l am `c� PH` I OHNE qe � °� r - h N OWNER NAME o ��1/7 V !t V L a= _ 0 3 `( Fr cu CITY/STATE/ZIP L` OWNER ADDRESS - "1 NUMBER OF EMPLOYEES: V CONTRACTOR=)ajcjfPHONE CAPACITY /r Q V CONTRACTOR ADDRESS ❑ CITY/STATE/ZIP TYPE/MFG LICENSE III C-42 - C-36 NUMBER EXPIRATION DATE JO�THER �G� DISTANCE TO NEAREST: WELL �e -, � --1 fl r:FOC.RAPNICAL INFORMATION: Coordinates X _ Y 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,48 HOUR DVAN E OT10E REQUIRED FUR IN -PEG IIUN - - FLEE A - CALL ZUS SIGNED - ; �"I ' Z TITLE oo-oe r DATE Application Accepted By Final Inspection By Character of Soil to+ Depth of 3 F COMMENTS II' AA0 LSI i /;C I,r Dateti f Amount Date L Y –� I I4rea �� Employee ID# Lv l , SPECC61AL PERMIT - Approved by 1 s- s9oft, l 11. 1 , G'ti 17�wu1. ',2--na -0,&61 A, Permit/ Invoice # Permit ID# Service Request # 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14118 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION # TYPE OF WORK: -)<_NEW INSTALLATION I REPAIRIADDITION I ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL 71 OTHER /J NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: -7 NUMBER OF EMPLOYEES: SEPTIC TANK 5� 1 TYPE/MFG ✓4 7 • L CAPACITY /r Q V U gal #OF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) I6 LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF Lwes It Q i DISTANCE TO NEAREST WELL v ft FOUNDATION 1t PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It 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 It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE It 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,48 HOUR DVAN E OT10E REQUIRED FUR IN -PEG IIUN - - FLEE A - CALL ZUS SIGNED - ; �"I ' Z TITLE oo-oe r DATE Application Accepted By Final Inspection By Character of Soil to+ Depth of 3 F COMMENTS II' AA0 LSI i /;C I,r Dateti f Amount Date L Y –� I I4rea �� Employee ID# Lv l , SPECC61AL PERMIT - Approved by 1 s- s9oft, l 11. 1 , G'ti 17�wu1. ',2--na -0,&61 A, Permit/ Invoice # Permit ID# Service Request # 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14118