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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS A " ✓ CrTYIZIP M .�t�v CROSS STREET Id1A� n�• APN • - �1 - O7 PARCEL SIZE o• 9 9 d tv OWNER NAME_, �� R1 n/ h a/--W PHONE � OWNER ADDRESS 4 �/ '"-• C' 4 CRYISTATE/ZIP �j_ J•� n CONTRACTOR 1( ` � ✓ HONE O / re q—51, �1 4 CONTRACTOR ADDRESS �b go�/ S�+y CITYISTATE/ZIP I; L/'�G�JPV O LICENSE 6-42 L. C-36 OTHER NUMBER 45`�QYrEXPIRATION DATE / �' �'- �•' WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # 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 [I COMMERCIAL El OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTICTANK TYPE/MFG�R 3f7;fti CAPACITY v gal #OF COMPARTMENTS CZ ❑ GREASETRAP TYPE/MFG -*1 CAPACITY P gal #OFCOMPARTMENTSr_ DISTANCE TO NEAREST: WELL c" It FOUNDATION_17� ft PROPERTY LINE a S It ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES f l LEACHING CHAMBERS #OF LINES 3 LENGTH OF LINES ce 4 ft DISTANCE TO NEAREST WELL tO • it FOUNDATION 0 O , it PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE it ❑ SUMPS WIDTH it LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEA ST WELL It FOUNDATION ft PROPERRTYYLIINE ft SEEPAGE PITS NUMBER WIDTH A(PH ft DEPTH Its ' ft ((((((��`��` DISTANCE TO NEAREST WELL aMM ft FOUNDATION ft PROPERTY LINE I • 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. MINIMUM 48 UOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE DATE i �16 r EP TMEN SE INLY 9 Application Accepted Date Area ` Employee ID# Final Inspection By . Date, ❑ SPECIAL PERMIT-Approved by Character of Soil to th of Ft: iVSu p Soil Character: COMMENTS I� f z" oN•C e o • 'op Z S-'av Are - PE Sc Received Check#/ Amount Permit/ de INFO ash a itted Date Service Request# ly Invoice# Permit I 106 Z5•oo /Q 2 � I` '� YG, �� 4 ONSITE WASTEWATER TRTMNT SYSTEM PEOF 4/141I74I18 -/ � � Uproaded into Accela '�F��-