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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-HIEFUNDABLE PERMIT JOB ADDRESS CROSS STREET (:ALL ZU9 953-1691 FOR INSPECTIONS tXPIRES l YEAR FROM DATE ISSUEI W CITY2IP _51�VC� K 'L»n CA r ,APN ' O I) b D l / PARCEL SIZE A w -1 OWNER NAME l Q n )1l 1�1, t.0 + V ■M) A PHONE:' Lo "f "?_iz - OWNER ADDRESS Mo�c jelfle_ Cl I CITY/STATE/ZIP �.►��f}�G:IC 11 •� I S - CONTRACTOR 1/I a 1 .G(J %�1 G�L1-1ti l.�K L1 +Cy r• PHONE — CONTRACTOR ADDRESS Yd fits k 64 C] CITY/STATE/ZIP vmc'A o--'� . C_-4 *7 LICENSE ❑' C-42 ❑ 'C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE (/ KEPLACEMENT W UUT-UF-SERVICE SEPTIC SYSTEM UESTRUCTION INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: f NUMBER OF BEDROOMS: �3 NUMBER OF EMPLOYEES: P"Is'EPTIC TANK TYPE/MFG lid f-1-- ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL 166 't— ft ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY (S� C) 11gal # OF COMPARTMENTS '' CAPACITY gal # OF COMPARTMENTS FOUNDATION cl 7 ft PROPERTY LINE Z5'� ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES 620 ft hec - sh DISTANCE TO NEAREST WELL1 CNn ft FOUNDATION ft PROPERTY LINE .[�I ft ❑ FILTER BED WIDTH ft LENGTH v ✓ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH pp�� ft DEPTH A YW&AL—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 I1NE y ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH A _ JOf- U16 ft DISTANCE TO NEAREST WELL ft /, FOUNDATION ft PROPERTY iS 1f?O/V /V OIJ ft 4Y SEEPAGE PITS NUMBER L4 WIDTH3r/ rr ft DEPTH �r p�9RT� � ft DISTANCE TO NEAREST WELL f ft FOUNDATION PROPERTY LINE ft �T v kHEREBY 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 JQOR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE_jr,6 YX Ce, I— DATE Application Accepted Final Inspection By Character of Soil to 11 COMMENTS I DEPARTMENT SE ONLY Date �' Area � Employee ID# Date P SPECIAL PERMIT 1 -/Approved by of 3 F Pit/Sump Soil Character: <IvL �Sf '�-_I.LA�7 PE SC INFO Received B7 hec - sh Amount Remitted Date Permit/Code Service Request # Invoice # Permit ID# k,1.to 1I -r 2A 3. 71'i 1� L,L'-1 �UL�'ki 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12 T