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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 gALL 299 953-76,97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS gal # OF COMPARTMENTS Cl/ /ZIP f t/% / , Off/ — /Y —04 / CROSS STREET ft FOUNDATION L APN PARCEL SIZE OWNER NAME ��/i�Ii rr nn i �/ ��f�Jy/l�i(�o / PHONE IO15J1 OWNER ADDRESS/CITY/STATE/ZIP DISTANCE TO NEAREST WELL CONTRACTOR �I—O'Se— [' PHONE/ MOUNDED CONTRACTOR ADDRESS ft LENGTH CITY/STATE/ZIP ft DEPTH ft LICENSE I_IC-42 1.1C-36 OTHER NUMBER ,,��7� 4 /!/ EXPIRATION DATE � �/ % TS WATER TABLE DEPTH: ft GEOGRAPHICAL I ❑ PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION REPLACEMENT F MATION: Coordinates X Y LAND USE APPLICATION # R PAIR/ADDITION ENGINEER DESK OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: �K-- RESIDENCE Ll COMMERCIAL Ll OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: -.y NUMBER OF EMPLOYEES: .TERNATIVE 9 SEPTIC TANK TYPE/MFG CAPACITY �� gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS WELL DISTANCE TO NEAREST: WELL 5 // ft FOUNDATION L ft PROPERTY LINE / � ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) AD-VANC&NOTICE REQUIRED FOR INSPECTIONS - SIGNED i� / / / TITLE I � DATE / A R T M E N T V SE 0 N Lj d Application Accepted By EPDate Area Employee ID# Final Inspection By Date ❑ SPE IAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS 64,P It d -U PE LEACH LINES ❑ LEACHING CHAMBERS Che ash # OF LINES LENGTH OF LINES ft Date Permit/Code Service Request # 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 It 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 LI E ft It SEEPAGE PITS NUMBER _ WIDTH ft DEPTH /fj� ft DISTANCE TO NEAREST WELL ft FOUNDATION 2L ft PROPERTY LINE S1 ,�4 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. AD-VANC&NOTICE REQUIRED FOR INSPECTIONS - SIGNED i� / / / TITLE I � DATE / A R T M E N T V SE 0 N Lj d Application Accepted By EPDate Area Employee ID# Final Inspection By Date ❑ SPE IAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS 64,P It d -U PE SC INFO Received B Che ash Amount emitte Date Permit/Code Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12 91