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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 [ION-REFUNDABLE PERMIT CALL 209 953.-X17697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE 6SSUED JOB ADDRESS G L� V\/ CITY/ZIP e—) �j 17J C�-0 y CROSS STREET APN 030 PARCEL SIZE // C OWNER NAME S �i � PHONE 2>-()C/ OWNER ADDRESS I U I C N�d I=Z I )y �' L( iTY/STATEIZIP CONTRACTORWi�L+�,. aLL Cr)',l Sf- PHONE 2, x" �1 CONTRACTOR ADDRESS `T� F"I t I /V C QQ�� CITY/STATEIZIP I� l_�� Sc7`L� LICENSE [111C-42 ❑❑C-36 OTHER INNUMBER 302 EXPIRATION DATE /!_i 31 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ . PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: U NEW INSTALLATION /r es—REPAIR/ADDITION Li ENGINEER DESIGNED/ALTER N T)VE EI ` ❑ REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM l� DESTRUCTION INSTALLATION WILL SERVE: 13�-IESIDENCE OMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ( 'rAICLE7`O CAPACITY � LL' gal #OFCOMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL /�y.� ft FOUNDATION •� (x� ft PROPERTY LINE SC ft ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) �� `If-LEACH LINES ❑ LEACHING CHAMBERS %or` / LINES I ES — LENGTH OF LINES DISTANCE TO NEAREST WELL ( FOUNDATIION 11 ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft �7 DISTANCE To NEAREST WELL ft, /FOUNDATION ft PROPERTY LINE ft & L SUMPS ?� WIDTH T / ft LENGTH �f / ft DEPTH / ft DISTANCE TO NEAREST WELLI !�r�' ft FOUNDATION �V ft PROPERTY LINE L' 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. MINIMUM` B—H R NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED �ITLE z'l� i DATE y/., O. 0-0) Tj w i( Up `f G s F DEPARTMENT USE ONLY �yN A 'Pp"batior Accepted E ^ n Date to Area Employee ID# Final Inspection By Date /X,-y / ❑ SPECIAL PERMIT-Approved )y Character of MSoil Depth of 3 Ft: Pit/Sump Soil Character: �� COMENTS . APJ , / PE SC Received Checl(# Amount Date Permit/ Invoice# Permit ID# Code INFO By ash Remitted Service Request# I ' 3000 3 00 1030 A 'z-N, 00-1 C1 20 9 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12