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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 p� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS—...l??� E L • Y t t"'�S_rT*-a^� G.__CITY21P �D I �I Z�•F U s CROSS STREET _ rn�Gr`� u_�` t- _ _ APN c)S rr- (�--4 S- /PARC\EL SIZE IOL•, OWNERNAME `)/V-i ID_I{1L.LOPQ SIO �ID'CAL CDN, 1\-V�-TDI_S -TPHHOONlE�(��O)-lip 2-cT4(OL F OWNER ADDRESS 34 I(t N(.�D IJ RJ>• CITY/STATE/ZIP S T wrT7rj eA CONTRACTOR LIQE t � W p, O rOO-'— GtUEvNI/IRO[OME^/�9"L- PHONE 3�y' D3-15- p CONTRACTOR ADDRESS r • V,p1 - s7r. c- CITY/STATFJZIP L 04o 1 C-A I 14 L) LICENSE C-42 C-36 OTHER C f;U _ NUMBER_ J E%PIRATION DATE WATER TABLE DEPTH:_ It GEOGRAPHICAL INFORMATION: Coordinates X �( PERC TEST # Z BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM 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 It 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 It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE It ❑ SUMPS WIDTH It LENGTH ft DEPTH fl DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE If ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH it DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It 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. NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 2953-7697 SIGNED_ ---_ _ ._. _--_.-- TITLE O/2 DJ. X11642 • DATE >>=I-k- s c i P?tAS.�� y �i@bS+� - Axa Ela = j' IT I ISI l k- �. ..i•_f. - c+ ------- L—! � o II 1 I - - �� '� DEPARTMENT,USE U/ S Application Accepted By — n Date S /i`'//.70: AreaC Employe Final Inspection By r•yra�.i[pe. yc,r'-1 Date ^ �,Z SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: - Pit/Sump Soil Character: COMMENTS 2ng,) N� fryAl PE SC Received heck Amount Date Permit/ Invoice# Per Code INFO B Remitted Service Request# ))] S-a3 s30 4?01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4 14 13