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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 GALL ZUY Yb3-/6y/ FOR INSPECTIONS ,,//,,�� LXPIRES "I YEAR FROM UA I E ISSUE! JOB ADDRESS 77 CJ a tt (� (�yCit/ CITY/ZIP �t� 1, s fi1� r G'/�i` g r a3% CROSS STREET I, C. APN i-) (DbU00 OS PARCEL SIZE 1 OWNER NAME -E �V -^ a t �Tw c I\d �A if y-G� C0 -n ' ^ PHONE � f c� OWNER ADDRESS O, 0 I 1 K ce"I / YW CITY/STATE/ZIP /lZ-l-` j't�Gi� r � CONTRACTOR IM I l/tet �2e--4 )'t PHONE q�i/V CONTRACTOR ADDRESS �� E�nX t� h p CITY/STATE/ZIP 4V A^ Le f G�� -3 �(i LICENSE ❑❑C-42 ❑CIC -36 OTHER NUMBER 1. % 0 � EXPIRATION DATE ri 2 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y_ ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: 0 NEW INSTALLATION REPAIR/ADDITION LI ENGINEER DESIGNED I.1 REPLACEMENT iJ OUT -OF -SERVICE SEPTIC SYSTEM I.I DESTRUCTION INSTALLATION WILL SERVE: &eFKESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: ( NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: TERNATIVE ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS heck ❑ GREASE TRAP TYPE/MFG CAPACITY gel # OF COMPARTMENTS Invoice # Permit ID# DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES S") I ft DISTANCE TO NEAREST WELL ft FOUNDATION wl ft PROPERTY LINE IOI 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. MINIMUM 48 HOUR ADVA CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953 697 SIGNED TITLE Gb✓1�-iGa i DATE DEPARTMENT USE ONLY Application Accepted � By Z, Date A rs i Area �� Employee ID# A Final Inspection By Date ZZ- ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: -1l Pit/Sump Soil Character: COMMENTS 1 It 1<0 <OG)ctiT�'Ci� vJ f -7 r PefMlfs 0%-) r"k Uhap,r r -I c- ot'C-c- PE Code SC INFO Received By heck Amount Remitted Date Per Service Re qu st # Invoice # Permit ID# 42-01 42 01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14118 ?A-