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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 ,rte CALL 209 953-7j697 FOR INSPECTIONS EXPIRES1 YEAR FROM DATE ISSUED JOB ADDRESS I J jLK10 1- II t l JZ'h y / ,6� CITY/ZIP 4�6t V5\6122— CROSS STREET (C t7i-IC � � APN 0,,7,/+ 0 I-Q PARCEL SIZE - ( o OWNER NAME C _P cy 13 PHONE OWNER ADDRESS 13 t 6"r Z'-- CC q i �C 2 `,� CITY/STATE/ZIP L>rt I k / / r �7 CONTRACTOR � ��i � //,//i�1n,J i IIS/ PHONE Fc CONTRACTOR ADDRESS t, 11.z f` CITY/STATE/ZIP LICENSE /C-42 I C-36 OTHER NUMBER `7�3 u� EXPIRATION DATE (p / 30 J 2d Z 0 WATER TABLE DEPTH:�,4-O Jy ft GEOGRAPHICAL INFORMATION: Coordinates X Y U PERC TEST # I BUILDING PERMIT# O LAND USE APPLICATION# TYPE OF WORK: y NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: /RESIDENCE ] COMMERCIAL L1 OTHER NUMBER OF LIVING UNITS: /v NUMBER OF BEDROOMS: / NUMBER OF EMPLOYEES: I SEPTIC TANK TYPE/MFG f CAPACITY / gal #OF COMPARTMENTS -T- ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL �j n�%i ft FOUNDATION 'rc) ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES Ste _ _ ft 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 ft 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 LINE ft U( SEEPAGE PITS NUMBER WIDTH 1 ft DEPTH ft DISTANCE TO NEAREST WELL-AXe It FOUNDATION / ft PROPERTY LINE 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. MINIMUM 24 .HOUR AD ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED - •�— TITLE [/G '��'( DATE J q IRC C:)U Pq C -0 PARTMEN SE ONLY Application Accepted By Date / / Area Employee ID#� Final Inspection By Date A I ' SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE Sc Received heck#/ Amount Date Permit/ Invoice# Permit ID# Code INFO By as Remitted Service Re uest# 415 G SP. LX-)& 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12