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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 PERMIja r► CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS t5-7 0- CITY/ZIP 5f-dC-x 1b✓I ick- 'T iA # x CROSS STREET ---�a� L, (Ile Ss APN �I- d ,� U PARCEL SIZE I 0 '9 4 3 ?` OWNER NAME is �r�� L �� / ��t�t .`� !�� PHONE J -7 '�.J1�`i A OWNER ADDRESS J�'yY�Gr CITY/STATE/ZIP �f'.9�-<� �'rj JjL�,� CONTRACTOR (11 , �Lr(C� rS C PHONE al kC -9- Gj CONTRACTOR ADDRESS iZ _� LE�.� X LI CA CITY/STATE/ZIP C ',4- oaf?" LICENSE ❑ iC-42 ❑ i_'iC-36 OTHER NUMBER (0e%&qi-S4XPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # r LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DES REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: C,41FSIDENCE ❑ COMMERCIAL NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ❑ SEPTICTANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG ❑ LIFT STATION LEACH LINES CAPACITY CAPACITY DISTANCE TO NEAREST: WELL ft FOUNDATION SIZE TYPE OF PUMP ❑ PKG TX PLANT LEACHING CHAMBERS DISTANCE TO NEAREST ❑ FILTER BED WIDTH WELL :561 ft ft LENGTH ❑ OTHER NUMBER OF E gal # OF ¢ X Ift"" ►� �V gal # OF COMPARJ i101�TA�� ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES _I FOUNDATION I ft ft LENGTH OF LINES y 6 ft PROPERTY LINE S -t 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 It re SEEPAGE PITS NUMBER _ WIDTH 2 1, It DEPTH ^.1-4cI ft DISTANCE TO NEAREST WELL � ft FOUNDATION I110' ft PROPERTY LINEft 1 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 HO DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE 66 iii�DATE ri [ DEPARTMENT SE NLY _ Application Accepted 13Y L Date 2 Area 0 X Employee ID# Final Inspection By Date -2 ([' A SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Gl fit. Pit/Sump Soil Character: 3acvr�l/ sJtz 2� COMMENTS 11-1,- t V b2 l t VI . PE SC Received eck Amount Permit/ Code INFO Bv Remitted Date Service Request # Invoice # Permit ID# 2 17 1793 -15-5,"" 212119 ' c. 42-01 4/24/12 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT