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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 A ,CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CROSS STREET I�r CITY/ZIP --:> I a cz—1y/tom APN'0131 I zo3z PARCEL SIZE `' — OWNER NAME ]A�% •1"1OIE� PHONE ,�� 16/4 —C) (o V OWNER ADDRESS r-�V"q7 A1E CITY/STATE/ZIP A C 1 "A G CONTRACTOR (�/ 1 //( PHONE �O�J�%j "J� 7 �( 7 SX CONTRACTOR ADDRESS ) A✓e CITY/STATE/ZIP �/ / LICENSE ❑ C-42 [IC -36 OTHER NUMBER 107010 n EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIG ED /AL ERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION C INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: �j NUMBER OF EMPLOYEES: /4 CAPACITY t�V Uy gal # OF COMPARTMENTS SEPTIC TANK TYPE/MFG pct oC ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL C201101, 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 Amount Date Permit/ Invoice # Permit ID# DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE BV ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH- ft DEPTH 4 DISTANCE TO NEAREST WELL ft ft FOUNDATION PROPERTY LINE LI DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ` DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE T 1 HEREBY CERT) 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. MINIMU 48 H U ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 \ TITLE V VU �j C. L DATE % �(�- �) IGNED f� ?C � N 2 0 ft ft ft ft ft ft ft ft ft ft ft ft DEPARTMENT USE ONLY `/►T Application Accepted By { Date rea t Employee ID#_ Final Inspection By 19 Date Z ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: CT`�� — LC COMMENTS P W i k",► C tL 54(n 6�,-,e ver�l;%� ��ti� �� H e �- ll14 PE SC Received Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO BV ash Remitted Service R quest # `amu, Oo g 42.0, &51v"� / 38 0 SI `Z3 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14118