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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 ..vn-ncrun UADLC rCKMU II T U, t,ALL LUy yJ3-/Oy/ FOR INSPECTIONS I - EXPIRES 1 YEAR FROM DATE ISSUE JOBADDRESS ISa0k ISI 1�/ II1Q,h LlJ'((,t Vo-& (jCITY/"ZjIP_ �(,J�d / C{ CROSS STREET /�t,Ke;4`Lz ww L c,,,y t- APN__ O L( 9 - 010 /�P/A�R(�CEELSIIZ^E 1-A o-& OWNERNAME QC1VNA( f- Zc mc,V1 PIHONE!`,I�TIJI J �D O•S� {� Ol. ` OWNERADDRESS S CL c \ CrrY/STATE1ZPP /�rL.0 1, ("&- 99SI aq o CONTRACTOR I I O (%/�\CA myfkw ;J � PHONE (916q) JI 33! j — (p 6 `3 CONTRACTOR ADDRESS o ig [1X -x1 o j -1 -7 CFTY/STATE/LPLna ��7In GSA.. -I5Aq j LICENSE ❑-IC-42 Ll ---C-3636 OTHER k� NUMBER ��0. 1 EXPIRATION DATE V'I//jy/qt ()�] .,1•'1 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y X PERC TEST # 1 BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION 7 REPAIR/ADDIITON Amount ] ENGINEER DESIGNED /ALTERNATNE Permit/ 1 REPLACEMENT " I OUT -OF -SERVICE SEPTIC SYSTEM -1 DESTRUCTION FiNS�TAL�LATJONILL SERVE: ❑RESIDENCE ❑ COMMERCIAL Invoice # Permit ION Service Re Uest # ❑ OTHER S�3 nnNG UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPEIMFG 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 ft FOUNDATION ft PROPERTY LINE ' ❑ FILTER BED WIDTH R LENGTH ft DEPTH �h$ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE /��n�1''ft�/ 13 DISPOSAL PONDS WIDTH LENGTH ft _,�./O/pg C' DEPTH ' \(J _ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ^,L,]�Q—E/.YA•• C ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL 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. •-•••--•••--••• � .••. .�.�..+...+�..v •.v�.�� v.n�a., rvrc 'cC.ir SIGNED TITLE- rv�l�li l./Y�C)t DATE Vw1T 6 V,® 2072 11 DEPARTME T U E ONLY C� Application Accepted Date (P Z ea / Employee ID# Final Inspection By Date Z Z ❑ SPECIAL PERMIT -Approved by Character of Soil tothrof 3 Ft: PiUSump Soil Character: COMMENTS j 1.) T7",L, / '- L, CFI PE SC Received Amount Permit/ Code INFO Cash Remitted Date Invoice # Permit ION Service Re Uest # 22-7- S�3 1017 ib��.•� 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14118 T