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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Joe ADDRESS ( I ci " ! h f CITY/ZIP ` ? L5 �7 �i CROSS STREET 1 I�IiY /� C� APN i rrS - - 4t - p:-��C tom' PARCEL SIZE OWNER NAME v C"pill: INSTALLATION WILL SERVE: L RESIDENCE PHONE OWNER ADDRESS %e-- h' L' h):: >< �L1� L� `"--3(Ltie •\ // { [ CITY/STATFILP ❑ SEPTIC TANK CONTRACTOR 1♦L J �%i� �1, r')&-1 ,Ie,,A Tild, hl iak' 4xi Y��PHONE /��[, LC-'-- 9�L'�8�� CONTRACTOR ADDRESS 'I ls_ I% / e r P,,, se (L7,Z \v 5-�� C.`iTITY_/STATEIZIP I ; Ln ri"� LICENSE I._ C-42 _ C-36 OTHER (� NUMBER 4 f EXPIRATION PATE % 3. WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X V PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION _ ENGINEER DESIGNED /ALTERNATIVE ft FOUNDATION REPLACEMENT _ OUT -OF -SERVICE SEPTIC SYSTEM _. DESTRUCTION INSTALLATION WILL SERVE: L RESIDENCE L COMMERCIAL L OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPEIMFG CAPACITY gal # OF COMPARTMENTS ❑ MOUNDED DISTANCE TO NEAREST: WELL ft FOUNDATION R PROPERTY LINE R ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) O LEACH LINES LEACHING CHAMBERS Check#I Amount # OF LINES Code LENGTH OF LINES It Cash Remitted DISTANCE TO NEAREST WELL yV ft FOUNDATION ft PROPERTY LINE it ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE It ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft=OUNDATION ft PROPERTY LINE R ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, grtW E LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. ?1 v7y / UCYAK I MC U IV I 3C N r Application Accepted 4 4 Date UZ,. Area V' L1 Cl Employee ID# F�•1 (� ••I� _ Final Inspection By Date 2 L SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS CSS rG O C_o T> IVO c- k-��K l A R h PE SC Received Check#I Amount Le Permltf Invoice # Permit ID# Code INFO B Cash Remitted Se ice Request # yV 16'A i -a E 42-01 IlilVDTI lII/�/11 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4114/1B v