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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 VERMIT UALL JOB ADDRESS U CROSS STREET f -lemon + y5J-/by/ FOR INSPECTIONS tXPIRES I YEAR FROM UATE ISSUE] CITY/ZIP � 'r1�C/C.,�flr APN 10106 ( 11 PARCEL SIZE +�� OWNERNAME l_'(0Ce0 Sreahen jA LEACH LINES PHONE hec / as OWNEikADDRESS SHR Seciyoye CITY/STATE/ZIP Se, Die4o 90130 CONTRACTOR �O�QIC�� Sec.,e PHONE /-&f-If CONTRACTOR ADDRESS Z / I-" �T Mme%✓� { �+✓ /` CITY/STATE/ZIP ft PROPERTY LINE ft GC/o, cg r LICENSE 0❑C-42 ❑0C-36 OTHER NUMBER J t `fJ 3 EXPIRATION DATE ft -7✓2V ? 3 ft WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: ❑ PERC TEST # BUILDING PERMIT # TYPE OF WORK: ❑ NEW INSTALLATION l& REPAIR/ADC Coordinates X Y LAND USE APPLICATION # IN 171 ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: A RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION _ ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) I 0 -M LEACH LINES ❑ LEACHING CHAMBERS hec / as Amount Remitted # OF LINES LENGTH OF LINES O ft Invoice # Permit ID# 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 Qi SEEPAGE PITS NUMBER 2 WIDTH 3 ft DEPTH Z ✓ '--` ft DISTANCE TO NEAREST WELL_,,oJJ ft FOUNDATION ft PROPERTY LINE I r ` 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. SIGNED r� DATE _r / ! r Z(j Z. 2 DEPARTMENTU S E 0 N L Y Application Accepted By Z12-- Date 5_111aa Area G% Employee ID# fAvi k Final Inspection By rimX—z Date S :Z VZ ❑ SPECIAL PERMIT -Approved by Character of Soil to Depth of X.3 Ft: IP Pit/Sump Soil Character: COMMENTS Qnr%+eymI rierJ, ner 4, /Ila paisLIn4 peo,-, fs on rjPr Se -121, _ E,tisdillS 11)7eS i'o PE Code SC INFO Received By hec / as Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# ya�0 i1� — _�320 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14.13