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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN �'UAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 74zfCan1 lVil �CfITYIZIP'_l_brr%�� jrT�j"_q r)r CROSS STREET � APN V / �!� V - V 1I PARCEL SIZE OWNER NAME OWNER ADDRESS CONTRACTOR CONTRACTOR ADDRESS y LICENSE FIC -42 CC -36 1,17 PA PHONE �/ i L— CITY/STATE/ZIP l��/�%��iA _uZ L Y�gl�f,4�vN- CA�C�� PHONE � � �l_'1�'J T / ip ! CITY/STATE/ZIP OTHER NUMBER EXPIRATION DATE C 7 ] LG WATER TABLE DEPTH: U lJ ft GEOGRAPHICAL INFORMATIO COordina s X Y xf ❑ PERC TEST # BUILDING PERMIT #j�y,jLAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION RE AIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ESIDENCE U COMMERCIAL _l OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: "�- SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS77--- ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS FILTER BED 1i DISTANCE TO NEAREST: WELL �� ft FOUNDATION ,4;7ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES n LEACHING CHAMBERS LINES I' Cash Amount emift,d DISTANCE TO NEAREST WELLy/" It # OF LENGTH OF LINES J ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft G DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH Aoi%_ IMPApp. ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH It LENGTH ft DEPTH I,, ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERT�kINE_ %nqn ft NNJOA ��j� ❑ DISPOSAL PONDS WIDTH ft LENGTH -ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPER 5 cVIRON � wyr%, ft SEEPAGE PITS 3 NUMBER 21, WIDTH '") ��q ft DEPTH !�-� qRr ft DISTANCE TO NEAREST WELL ft FOUNDATION / 4"> '1' ft PROPERTY LINE .4-- ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, 1_�01 STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. v►nvnv cw nvvn H6J rv�.c v►►t,c rsct,►v► cu r-vn ►►v�rcL-►►vrv� - rc.cH�c LHLL Lvy yO3-�oy� SIGNED -tiF/' TITLE DATE �. Application Accepted Final Inspection By Character of Soil to COMMENTS Ft: 11 Date Date T S 5ODLL Y Area Employee ID# _ ❑ SPECIAL PERMIT - Approved by it/Sump Soil Character: PE Code SC INFO Received By Cash Amount emift,d D to Permit/ Service Request # Invoice # Permit ID# G s0 7 3 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12 n