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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-KEFUNDABLE PERMIT CALL (LUY) y5J-/tiy/ FOR INSPECTIONS tXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS 4/ PeW-ii1Vr, `�i CITY/ZIP S Vcx 70^ �'� r I CI CROSS STREET Re" V t--, / APIN C PARCEL SIZE OWNER NAME-LS%/yl^�ll�' L l� i4L%A,o/� 1r /l� t7,, at A F g J PHONE cppq (K;2 OWNER ADDRESS /.�`'� TYX5�/�yW CITY/STATE/ZIP � } �E��1'` �7 �� 151'7T" ` CONTRACTOR �/ S f �� PHONE CONTRACTOR ADDRESS �/ �4- CITY/STATE/ZIP LICENSE 11nC-42 11FIC-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # Code LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ENGINEER DESIGNED /ALTERNAT VE 075- ►� 17REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION SPfZ INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: O SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS 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 ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 HEREBY CERTIFY THAT I H A,� 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. SIGNED VR 11yarcl-I1wMa - rI-GmoJ L'ML-1L ILV.71 .7:JJ-/ VJ/ TITLE /JGrI ✓ �' ^ DATE J V/✓� ��`� DEP ARTMENT,USE ONLY 5 tbck4wi �J�j Application Accepted B C%L Date �� Area R Employee ID# Final Inspection By Date t— ❑ SPECIAL PERMIT -Approved by Character of Soil to Dt pin of 3 Ft: Pit/Sump Soil Character: COMMENTS Cwi ne- & 4 -fib lY sewer PE SC Received Check#/ Amount Permit/ ate Invoice # Permit ID# Code INFO By_ Cash Remitted Service R ue t # Haa 075- ►� l5 4(/'?r 120 I (q q f,-2— ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14//14/ 18 � V,