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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 9IQLa;111111►191-11-111111addl JOB ADDRESS e7 LXPIRES 1 YEAR FROM UATE ISSUE[ CROSS STREET 1 ZA - APN CA -I o PARCEL SIZE . OWNER NAME y' .4- e_/ {� ,/�/� C �`y PHONE 3 �_ `,) b 9__<�TER BED 6'65 S �uAIanI /5/� cA�3.1 OWNER ADDRESS SIZE TYPE OF PUMP - ./ ��'� 'V CITY/STATE/ZIP ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH cGA �/�y CONTRACTOR �Y 1 .j I1/ 1 �. x CL ems' S R. PHONE iq 9, -' E & CONTRACTOR ADDRESS �T/(� '1i 4z CITY/STATE/ZIP �r �di/�Gl�i G✓T ��•��G LICENSE ❑i C-42 ❑ _C-36 OTHER NUMBER EXPIRATION DATE FOUNDATION ft PROPERTY LINE WATER TABLE DEPTH: l ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # � 7� - LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: 1.YF IESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: Q'- SEPTIC TANK TYPE/MFG �`� �- CAPACITY PCZ ��_ gal # OF COMPARTMENTS_L� ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS 9__<�TER BED DISTANCE TO NEAREST: WELL ft FOUNDATION t 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 ft Amount Date Remitted DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 9__<�TER BED WIDTH �;>p 45 t ft LENGTH___3 d/ ft DEPTH I k F 1 ft -i�g S9 DISTANCE TO NEAREST WELL ft FOUNDATION I c�i r ft PROPERTY LINE K 1 t 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 ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft 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. SIGNED Application Accepted B Final Inspection By Character of Soil to Depth of 3 COMMENTS VANCE NOTICE RE vrl nvOrcL, a 4.i4LL (LUV/ you-ioyi t TITLE ��` ZI1_} d�C> DATE �rr7 DEPARTMENTUSE DNL Y Date Area d�lEmployee ID Date C/ IJ SPECIAL PERMIT -Approved by Pi Sump Soil Character: PE Code SC INFOB Received Cash Amount Date Remitted Permit/ Service Request # Invoice # Permit ID# -i�g S9 ° 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12 V,