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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 JOB ADDRESS I CROSS STREET GALL assuN YO6-/0`J/ FOR INSNtGIIUNS CXNIKtS I T tAK t-KUIVI LJAI t IJJCUI O 1 CITY/ZIP APIN CD PARCEL SIZE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: 0 NEW INSTALLATION LI REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT J OUT -OF -SERVICE SEPTIC SYSTEM CI DESTRUCTION INSTALLATION WI SERV : RESIDENCE COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 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 ft SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES [I LEACHING CHAMBERS Received B OF LINES OWNER NAME ft PHONE P0 44we., /x /C 6 v' Jc4SOWNERADDRESSv FO UN ATION CITYISTATE/ZIP ft CONTRACTOR // I / PHONE S ^ :SJ CONTRACTOR ADDRESS L% J/ C`^l CITY/STATE/ZIP r SS3sr LICENSE LIC -42 LIC -36 OTHER 1 NUMBER?- EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: 0 NEW INSTALLATION LI REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT J OUT -OF -SERVICE SEPTIC SYSTEM CI DESTRUCTION INSTALLATION WI SERV : RESIDENCE COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 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 ft SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES [I LEACHING CHAMBERS Received B OF LINES LENGTH OF LINES ft Permit/ Service Request # DISTANCE TO NEA MT WELL ft FO UN ATION ft PROPERTY LINF ft 2 FILTER BED WIDTH ft LENGTH Z_ft DEPTHZ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE J ft MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft PAYM/ EM'jSUMPSWIDTHftLENGTHftDEPTH1 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE RCEIVEI DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION y ft PROPERTY LINE r1 U 7 7 SEEPAGE PITS NUMBER ft DEPTH PROPERTY ft 1 DISTANCE TO NEAREST WELL ftft FOUNDATION LINE CAI\/IOP1\I. RIM MEIHEREBYCERTIFYTHATIHAVEPREPAREDTHISAPPLICATIONANDTHEWORKWILLBEDONEINACCORDANCEWITHSANJOAQUINCOUN STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMU 48 HUUK AUVAIVGt IVU IIL r- KC: UIKCLI rUR iiVJrCl, I1V1Vu SIGNED / TITLE r Nt" ' DATE 2 o x2;.e. 25C j o RApplication Accepted By y VV Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS f u V so{Z DARTMENT USE ONL ZZ Date a ea l Employee ID# Date_2ZZ-. SPECIAL PERMIT - Approved by Pit/Sump Soil Character: U/I+` LS D P / I ! X I - fU +C1 I Cil - l I X I r Lw S 6 -t -k- ol- rl PE Code SC INFO Received B Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 10c i 2 t 0191412 42-01 L/ , ` IT Y -M ;VI -0— v — e ' v O (I l r` 'v ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14118