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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT PNO OAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 488-3420 REFUNDABLEpPERMIT CALL 209 953-7697 FOR INSPECTIONS AEXPIRES 1 YEAR FROM DATE ISSUED DDRESS � 9 _i Wl�R O�jE L I A7 (r7i 1' SCITY/ZIP AC ALM, Pb STREET S' CCP,) lA APNy03—Ivo-14v PARCEL SIZE Z• I 'd� OWNERNAME (-TODD I+VSWtE1z)2o9 • g9t-993S— PHONE OWNER ADDRESS 497-1fe &VLpCN 1-trOi711L.L- Ly CITY/STATEIZIP r -L- Z>61ZADO HILLS {LLS C A CONTRACTOR L- I V E 0 A K(� EO En1V 1 KO>`/ f1'1 EN i pt LPHONE 3 (.1- 015" C)S "1 `Z. CONTRACTOR ADDRESS 1401 W L S' • aA 1T CITY/STATE/ZIP L- rD ( CA -t p Sl L4 Q LICENSE ❑ i..:�C-42 OCC -38 OTHER C C Cr NUMBER Z (S I EXPIRATION DATE r"�' J - 7,4 WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X y DK PERC TEST #_ l BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: '„ NEW INSTALLATION ❑ REPAIR/ADDITION D ENGINEER DESIGNED/ALTERNATIVE I! REPLACEMENT 1..1 OUT -OF -SERVICE SEPTIC SYSTEM D DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ 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 (t ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ! LEACHING CHAMBERS - # OF LINES LENGTH OF LINES it DISTANCE TO NEAREST WELL ❑ FILTER BED WIDTH it LENGTH DISTANCE TO NEAREST WELLft El MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ❑ SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL L3 DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ❑ SEEPAGE PITS NUMBER WIDTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft R DEPTH ft FOUNDATION ft PROPERTY LINE ft It DEPTH ft it FOUNDATION ft PROPERTY LINE it ft DEPTH ft ft FOUNDATION ft PROPERTY LINE ft ft DEPTH If ft FOUNDATION ft PROPERTY LINE it ft DEPTH it 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. MINIMUM 8E UIRED FOR INSPECTIONS - PLEA E CALL 209 953-76,97 SIGNED ___ TITLE—1912-0-S (M (>(L . DATE DEPARTMENT USE ONLYp Application Accepted By �—/� z L Date JJ Area L-1 Date �t Ll Employee to ee ID# %J A Final Inspection By Date ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: _ Pit/Sump Soil Character: COMMENTS 42-01 4114118 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT