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�et�= ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SA41 JOAQUINOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 74ON-REFUNDABLE PERMIT GALL(Zt19 953-7691 FOR INSPECTIONS LXPIRES 1 YEAR FROM UATE ISSUEI JOB ADDRESS / 1"9- '! Q CICITY/Zip_ 4ISAT ��/ & CROSS STREET W id five, APN DT Z X12,0 3 PARCEL SIZE �' 4 OWNER NAME VQQ 1► I`':dm, V- l'a'r A'7 _ PHONE OWNER ADDRESS '?'90'6y -)C e',7,'*�c/` SZ-%((CITY/STATE/ZIP CONTRACTOR �yial �Q� PHONE _ iI©�� CONTRACTOR ADDRESS oil (e, 0Ismo Df- CITY/STATE/ZIP zlt!d . C LICENSE LIYC-42 ❑ C-36 OTHER NUMBER 4-25-70 /EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X _ _ Y � 1 ?ERC TEST # Check#/ Amount Date BUILDING PERMIT # LAND USE APPLICATION # _. INFO TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION O LO Ti4-0-r— INSTALLATION WILL SERVE: I ) RESIDENCE COMMERCIAL L OTHER_ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: l SEPTIC TANK TYPE/MFG G.. /� CAPACITY �Da gal # OF COMPARTMENTS__ ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS �� DISTANCE TO NEAREST: WELL �— �_7 ' ft PROPERTY LINE -50 ft ft FOUNDATION _ ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES7( LEACHING CHAMBERS a��C�CIWI �f # OF LINES �_ LENGTH OF LINES /00 ft '` DISTANCE TO NEAREST WELL SO -lr / / ft FOUNDATION IO ft PROPERTY LINE I%' ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH rN ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEyj ftj ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft0� _ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE El SUMPS WIDTH ft LENGTH _ ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION -ft PROPERTY LINEZ ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH W DISTANCE TO NEAREST WELL ft FOUNDAQTIOJV ft PROPERTY LING ft SEEPAGE PITS NUMBER WIDTH �C7 / _ it DEPTH S� ft DISTANCE TO NEAREST WELL /!!W ' ft FOUNDATION CSO ft PROPERTY LINE_ ft w I HEREBY CERTIFY THAs 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 Final Inspection Byt! Character of Soil to D COMMENTS � TITLE DATE -3- 0 -O a3/'c. U uA DEPARTMENT USEONLY p .4 'ztlDate 3 / Area -( Employee ID# Date Ll SPECIAL PERMIT - Approved by of 3 Ft: Pit/Sump Soil Character: L 4G€ �(�T � `FSTEM s��.GS f��-£c/I tluS < </ f►�u-o7�� !g5% .S' - �>t!/f-% -uJ - 7 OL— PE SC Received Check#/ Amount Date Permit]�— Code INFO B Cash emitted Service Request # Invoice # Permit ID# t — 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12 Fr