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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT Pv'� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 JOB ADDRESS CROSS STREET - - / OWNER NAME [�1_►�I�IC��1»Jkl•1rQL•�sll�il;�/►�bYJ�N'rL•lP��a 1:71:1�'lr �'��_la�ai]iriU�>tr� 6'�Yll��l 0 CITY/ZIP 'T APN /0/L/DO - 07 L�3 S' PARCEL SIZE PHONE Z1-7�9 ,'C-r—�2 OWNER ADDRESS - i / iLfJ/ f< ' 1CITY/STATE/ZIP �i . L 7♦ CJ [ 1�..�j7T �% �� F CONTRACTOR!✓ PHONE CONTRACTOR ADDRESS j�2��i(iY� ��f] CITY/STATE/ZIP d/"�� '� �✓i LICENSE EIC -42 LIC -36 OTHER NUMBER �� EXPIRATION DATE�� WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: I NEW INSTALLATION /X- REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT I I OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION;fjai LINSTALLATION WILL SERVE: X—RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: A(- SEPTIC TANK TYPE/MFG 1� CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY %% JJ gal # OF COMPARTMENTS_ DISTANCE TO NEAREST: WELL t� ft FOUNDATION T It PROPERTY LINE f� / ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES CI LEACHING CHAMBERS # OF LINES LENGTH OF LINES 4A ft Amount mi e DISTANCE TO NEAREST WELL ft �� FOUNDATION I/�7 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 FOUNDATION ft PROPERTY LINE ft . t to SUMPS WIDTH lft ft LENGTH / ft DEPTH r / ft / DISTANCE TO NEAREST WELL ft FOUNDATION ,%L% /-,Z- _� ft PROPERTY LINE f� / 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. IVIIIVIIVIA VI GY I IVVn PILJV47/VV /VV I Il -,L-: 1 /V/VJ - rLCM JC 1."MLL LU.7 9Jr1 UJ/ SIGNED TITLE DATE �. - ViEgLTHOE D PARTME T SE Y .��✓ Application Accepted By Date Z Area Employee ID# Final Inspection IS Date41 ❑ SPECIAL PERMIT -Approved by Character of Soil to Dept of 3 F . PiUSUmp Soil Character: COMMENTS PE Code SC INFO Received B (-CheckV Amount mi e D to Permit/ Service Request # Invoice #. Permit ID# Z 0 / S K CO 79a.5W 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12 T