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n ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 NnN-RFFIINnAFlI F PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP z�i?�_ CROSS STREET /�l ✓i 'S >�� APN D/�w—`0 • J J PARCEL SIZE OWNER NAME LD%Jyv PHONE OWNER ADDRESS /71�/C / CITY/STATE/ZIP CONTRACTOR �G/�'/J�/7L ��i�l /�/C� PHONE _36e1' -5-0Z;7 / CONTRACTOR ADDRESS CITY/STATEIZIP Zmz_ LICENSE §C-42 ❑C-36 OTHER WATER TABLE DEPTH: ❑ PERC TEST # NUMBER �57�`�S� EXPIRATION DATE G 7�1 ti r 2s"7 ( Nryvc=1J ft GEOGRAPHICAL INFORMATION BUILDING PERMIT # NEW INSTALLATION >< REPAIR/AD Coordinates X Y LAND USE APPLICATION #_ )N ❑ ENGINEER DESK REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: TERNATIVE ❑ SEPTIC TANK TYPE/MFG /�' % LTJ W (. CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS Permit/ # Permit ID# service Request # DISTANCE TO NEAREST: WELL ft FOUNDATION 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 y ft DISTANCE TO NEAREST WELL It FOUNDATION i ft PROPERTY LINE 5-6 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 IN; ft ,J lx SUMPS WIDTH y' ft LENGTH I 9� ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTIj tt DEPTH ft DISTANCE TO NE EST WELL SO FOUNDATION ft PRO PE TY LINE ft �. SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL FOUNDATION ft PROPERTY LINE G 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - OLEASE CALL 209 953-7697 SIGNED TITLES DATE ` S i N 11 I lip t �C P I F't N EPARTMENT SE 9!Nd= Y N Application Accepted B Date Area Employee iD# V Final Inspection By / ✓ Date ❑ SPE IAL PERMIT -Approved by Character of Soil to Ddpth t: Pit/ mp Soil Character: COMMENTS PE SC Code INFO Received Cash Amount emitted Dat ate Permit/ # Permit ID# service Request # � 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 9/21/10