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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 NON-REFUNDABLE PERMIT CALL 209 953-7697FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS kv Sifatt'A 'V)E� c ..CITY/ZIP_ C-�'�^E�1-"i_�__.CA �,�..Z� CROSS STREET - -- APN .._ .�. . ._ a _. _41 y ...___._ OWNER NAME !6 A4 A L^ti-1 Z PHONE OWNER ADDRESS ..r 1J A'�r, iA� A bt-4 Z d A /57 CRY/STATIJZ, _CA.: l CONTRACTOR `5 �S�1 t�^c4 IAA tr t I N PHONE efj CONTRACTOR ADDRESS J� -t` S I CITY/STATE/ZIP �� - C-� -15►�� LICENSE 0:C42 11:.!C-36 OTHER- A- NUMBER ��S`l _EXPIRATIONDATE '�J 2-0 CD WATER TABLE DEPTH:� (,� ft GEOGRAPHICAL INFORMATION: Coordinates X Y A ' i✓' PERC TEST #_..__..-...... —.� rBUILL61NG PERMIT# _. LAND USE APPLICATION lY_ ..____...._...._._...._...__ - L-_ -- TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESKINEDIALTEnwivE, J REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM .. DESTRUCTION. D INSTALLATION WILL SERVE: y RESIDENCE +7 COMMERCIAL L OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS:_...,._ ,�___. NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG Q�L• O _-._..__. CAPACITY_ ��N ®al #OF COMPARTMENTS 2 __ ❑ GREASE TRAP TYPE/MFG CAPACITY _ gal #OF COMPARTMENTS-—- DISTANCE TO NEAREST: WELL _ it FOUNDATION 10 4 ., it PROPERTY LINE ❑ LIFT STATION SIZE TYPE OF PUMP......,____-_.- Cl PKG TX PLANT Q SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES )t LEACHING CHAMBERS I yf�. j �rr� #OF LINES 1) LENGTH OF LINES CC7 n DISTANCE TO NEAREST WELL I k FOUNDATION 8 PROPERTY LINE _ it 3 ❑ FILTER BED WIDTH_ _ ft LENGTH _ ft DEPTH_ It DISTANCE TO NEAREST WELL___It FOUNDATION fl PROPERTY LINE it ❑ MOUNDED WIDTH__.._._................ it LENGTH _..._..- ft DEPTH_ it DISTANCE TO NEAREST WELL,_,_,__ it FOUNDATION it PROPERTY LINE it f1 ❑ SUMPS WIDTH ft LENGTH .—__ 1< DEPTH it DISTANCE TO NEAREST WELL -_f< FOUNDATION—,ft PROPERTY LINE it ❑ DISPOSAL PONDS WIDTH_ It LENGTH it DEPTH.— it DISTANCE TO NEAREST WELL__ft FOUNDATION_ R PROPERTY LINE ft SEEPAGE PITS NUMBER 3 WIDTH ��.��-._. ft DEPTH 'Lrb 1 ft DISTANCE TO NEAREST WELL_ ..a� it FOUNDATION J W_it PROPERTY LINE iv` it i I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAGUIN COUNTY, MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED _ TITLE ({,�D(.,d'J_.__�� DATE__y�_:_�� r Ie 2a - >r W 19 EPA T EN Y Application Accepted B r �_ Date........ Area Employee ID# 17— Final Inspection By _ Date_. �? _� ;:.J SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: PI ump oil Character: .............. COMMENTS (/ � �& 1 Pt _b 1-02AK A 6 11S ,I aI ep b PE SC Received Check#/ Amount Permit/ Cade INFO B Cash Remitted Date Service Ragusa# Invoice# Permit ID# 3 42-01 ONSITE WASTEWATER TRTMNF SYSTEM PERMIT 4/24112