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Q$q) ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUNDABLLE PERMIT 4:ALL LUy y5 /t) / FOR INSPECTIONS tXPIRES 'I YEA FROM UATE ISSUED JOB ADDRESS' �" '^ / P� y/� CITY/ZIP c/ /__1 f� CROSS STREET i(y / J(A /yr �� APN jTg00_3 PARCEL SIZE ; v OWNER NAME / �' [ II ll II� �T r PHONE OWNER ADDRES �l-/ pL� CITY/STATE/ZIP CONTRACTOR (i�2 PHONE �` C) 7 V CONTRACTOR ADDRESS —"�D CITY/STATE/ZIP LICENSE ❑!.IC -42 ❑f.1C-36 OTHER �% NUMBERC,5s-6,6_-�-cXPIRATION DATE 3 .tel Zo'z WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION ❑ ENGINEER DESIGNED IALTERNATI E REPLACEMENT OUT SEPTIC SYSTEM DESTRUCTION S' IC L INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG CAPACITY TYPE/MFG CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION SIZE TYPE OF PUMP ❑ PKG TX PLANT LEACH LINES L LEACHING CHAMBERS ft FOUNDATION ft DISTANCE TO NEAREST WELL ft FILTER BED WIDTH ft LENGTH DISTANCE TO NEAREST WELL 21 MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL SEEPAGE PITS NUMBER WIDTH_ DISTANCE TO NEAREST WELL 11 # OF LINES FOUNDATION gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft FOUNDATION LENGTH OF LINES _ ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE 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. —wilwivi lml'f0 r7VVlCVM1V.L C IVU IIL V- r%C VII[CU r-wrx Ilvor- /.L, I IVIYJ - rLC/YJC VPiLL .7 LV SIGNED TITLE �kiO--� t_' DATE 7 DEPARTMENT USE ONLY Application Accepted By 1' Date 11,2) 1,7R Area Employee ID# Final Inspection ByL_. jQA Date ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS ��/J ) _ , btJ+ SE '$1"_ CIP.S�' pol /00 nC',,wt, �, iheif S Ff,i La O% SI / K--,yj. Jo's PE Code ft ft FOUNDATION ft ft FOUNDATION ft ft FOUNDATION ft ft FOUNDATION ft FOUNDATION LENGTH OF LINES _ ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE 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. —wilwivi lml'f0 r7VVlCVM1V.L C IVU IIL V- r%C VII[CU r-wrx Ilvor- /.L, I IVIYJ - rLC/YJC VPiLL .7 LV SIGNED TITLE �kiO--� t_' DATE 7 DEPARTMENT USE ONLY Application Accepted By 1' Date 11,2) 1,7R Area Employee ID# Final Inspection ByL_. jQA Date ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS ��/J ) _ , btJ+ SE '$1"_ CIP.S�' pol /00 nC',,wt, �, iheif S Ff,i La O% SI / K--,yj. Jo's PE Code SC INFO Received By_ Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# Lpd ) o7S ,� )s� 21 �ti S 7 2 4 C M3 7 60'1 7S! ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14//14/ 18 T