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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 C JOB ADDRESS / y 4 U0- "q - CROSS STREET CALL 31- ;z � 95J-/69/ FOR INSPECTIONS tXPIRES "I TEAR FROM UA I t ISS, U/tU r4-/) CITY/ZCIP/�� 2 4 e . CA % 7 I APN , 0 n - ` F 0 PARCEL SIZE `� . V OWNER NAME AC.1=� r '-'�J /� d ;S •� PHONE / (,% -7 OWNER ADDRESS /✓� / �2 G� CITY/STATE/ZIP + S ' 2 U V L L / CA CONTRACTOR Q �'%{ I t� 0 ':�-z PHONE CONTRACTOR ADDRESS LICENSE ❑EC -42 ❑DC -36 OTHER CITY/STATE/ZIP NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y I R_❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: >41 NEW INSTALLATION I I REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE 1.1 REPLACEMENT J OUT -OF -SERVICE SEPTIC SYSTEM 0 DESTRUCTION INSTALLATION WILL SERVE: 9 RESIDENCE 11 COMMERCIAL El OTHER NUMBER OF LIVING UNITS: Li Xj! ` NUMBER OF BEDROOMS: :2 NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY I- o 0 gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 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. IIIIIYI/II III 40 VV r[ /4w V111YliG IV I ll+G r[G VIr[GL/ I-Vn IIYJr-GV I I{J11R7- rLGMJC L.MLL GV.7 JJJ-I VJI SIGNED -j/ CifT r'l /, 12e <J TITLE DATE- I/— 6`t —24'Z -I EPARTMENT U S Y.0NLY :PERMIT Application Accepted ByDate. % Area Employee ID# Final Inspection By�� vz,S-�,,e '',2 Date 'ZPZ-L- ElSPE -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS V . Q43 SIT' PE SC Received Code INFO By Amount Date Cash Remitted Permit/ Invoice # Permit ID# Service Request # l '1�121 S�2 LEACH LINES U LEACHING CHAMBERS # OF LINES LENGTH OF LINES 00 ft DISTANCE TO NEAREST WELL ft FOUNDATION L()14- 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 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. IIIIIYI/II III 40 VV r[ /4w V111YliG IV I ll+G r[G VIr[GL/ I-Vn IIYJr-GV I I{J11R7- rLGMJC L.MLL GV.7 JJJ-I VJI SIGNED -j/ CifT r'l /, 12e <J TITLE DATE- I/— 6`t —24'Z -I EPARTMENT U S Y.0NLY :PERMIT Application Accepted ByDate. % Area Employee ID# Final Inspection By�� vz,S-�,,e '',2 Date 'ZPZ-L- ElSPE -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS V . Q43 SIT' PE SC Received Code INFO By Amount Date Cash Remitted Permit/ Invoice # Permit ID# Service Request # l '1�121 S�2 42-01 4/14/16 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT v a 0 0 a N N ;91