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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - {209} 468-3420 NON-REFtINP &!7''_!F PE MIT LL 209 953-7697 FOR INSPECTIONS r rAK rMU1V1 ur%i F - 1Q11 JOB ADDRES CICIITY/ZIIPP APN -32- A PARCEL SIZE %Q CROSS STREET PHONE OWNER NAME /'/ OWNERADDRESS a i �-F CA- CITYiSTATEIZIP F,/� _ D' 1 4 — `� ` " PHONE � CONTRACTOR DISTANCE TO NEARE CITY/ST CONTRACTOR ADDRESS WIDTH I ft LEN H _ _ -k ft DEPTH o ft : I ]rFJ.qrVC-42 I IC -36 OTHER tp05 l l NUMBER ExPiRATION DATE _ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION ❑ PERC TEST # l BUILDING PERMIT #i TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIAD i REPLACEMENT uooramates A LAND USE APPLICATION )N L ENGINEER DI ❑ DESTRUCTION INSTALLATION WILL SERVE: 1 A RESIDENCE COMMERCIAL NUMBER OF LIVING UNITS: f `� �I NUMBER OF BEDROOMS: ❑ SEPTIC TANK TYPE/MFG�L5Tw41 CAPACITY ❑ GREASE TRAP TYPEIMFG CAPACITY DISTANCE- TO NEAREST: WELL ft FOUNDATION_ ❑ LIFT STATION SIZE TYPE OF PUMP L3 PKG TX PLANT ❑ OTHER NUMBER OF EM 9 gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERSQ�� # OF LINES �LENGTH OF LINES � ft Date DISTANCE TO NEAREST �y WELL I' 0 it x`/7.10 FOUNDATION ft PROPERTYLINE tt. D 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 NEARE WELL ft FOUNDATION ft PROPERTY LINE ft SUMPS WIDTH I ft LEN H _ _ -k ft DEPTH o ft DISTANCE TO NEAREST WELL ft �l FOUNDATION It PROPERTY LINE I©Q ft ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft D]STANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH it 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. MINE UM CE REQUIRED FOR INS CT 15 - P L (209) 953-7697 113 SIGNED TITLE DATE Application Accept) Final Inspection By Character of Soil to COMMENTS Area 1 Employee ID# (:7S-; I'�-- ❑ SPECIAL PERMIT - Approved by p Soil Character: PE SC Received Code INFO By Chec Cash Amount Remitted Date Permit/ Invoice # Permit ID# Service Re uest# 9 2 `7 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 10/4107 A