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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 NON-REFUNDABLE PERMIT CAS L 209 953-7697 FOR INSPECTIONS EXPIRES 1 Y . R FROM DATE ISSUED JOB ADDRESS r C' ' CITY/ZIP �' C �7�— CROSS STREET APN �S�q � a PARCEL SIZE OWNER NAME �Te �jl-�` vl'.9 ) GW�l4 PHONE -q . J ., r� OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I.JI_-'C-42 0',_IC-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y CI PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION 7 REPAIR/ADDITION ENGINEER DESIGNED,/ALTERNATE REPLACEMENT -1 OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION z� Cs INSTALLATION WILL SERVE: 1-1 RESIDENCE l.] COMMERCIAL OTHER L. wn NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS 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 L LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION 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 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. NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953 7697 _ SIGNED TITLE Lo-!A"Lt- G-- DATE ,.{ -rr }-;+' _s„+h'•�T I-. ��'�� I _.�_FH 1-i-t"1✓-�i H_--4` _ :._f"'I'��:• , _z*n7 I.C F s . ..y.._''_ .I !1a•:l:.:-_i-I J 1.` I �..L T 1- r.i..tt'k.iTi I rrF �- - I :1�.�.;.�,r/�?�`•�1� _j_ ;i:::,:...'..L�1-'.:«�' i-.t a r'_.is r t:i.�.,.� _ 1VT7�..� LLi�_r_.:.,1•'-I+, {- �''1 1'� 'HI -' �-i'LI'• _� rrl.y'-'t -J-i-}-'I '' -r.jy l },{_L 2LL:i _�� i'�'. �t �3. �.j;�-��?-`r�'.rl.�(-!:'��+I-•t�Tlt� }''`.i::.��7T�j.'.f-F-�7�:-_`tr.�i-`:i�l tj1t. T '1_..�J ,i-t-i �••'h-47' t-r IJ:'-Tl. T�-,I�i AT-Y ,r ti'I1 -C 'r+,i•� �i.�'.,_ri- I-.�_t. ::LL'.t.t I!-i.'.i• .rt fi_r is:r�.-.-L.._:Si�'H-1 j;- -i,_ t -'fit; �:- L tii __ rix _ .._., Ft*•� __ :-;r Lj_ T .t tir 1......1'T � :. ,_ t .L_ i1 {..1_ _1 L_ V.L. .;.. _. L'.I. J..i-{ry} .i. .I•_:J_ `L" - r .74- -!-T .i. t* -- -i -1-1:•''y"I-!-r,t' ;tom t - r i Y'Lf-'- t• r_I Y-r.i_I_'r f.l T. -l{ Llsa-. ,.:4 1 Lt 1" L: `r." JN-i�J1'LI",_ I-r ''�!k-` 1 r•I-I`Sr-�i. :'{yY{.1 � r} t'LI �I-I : i�;-1 4�t. t _��!' ♦ _'i_ ..�_r'1-1-L •�1_:;r,.:: .I_. 1 1 1 1 .TT 't rF-'� I�- ' .R�;-�•_r.{;� I'!�! rl I � ' '�T�.-�1..+ 4.1 i�. r�— Y T "t�y. r- 'l- r. .Jtl-I'A1 --L r-t 1 I Lrl fes, �+,-��-{•- 1 -Yf-- . r _L�-iY: -. 1� I1 .-1,r y.l' JY �1L I I J —( • P. DEPARTMENT SEONLY Application Accepted B Date r Area C Employee ID# " , Final Inspection By Date 1..-] SPECIAL PE MIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received Check#/---) Amount Permit/ Code INFO B Cash/ Remitted Date Service Request# Invoice# Permit ID# .;4) � ) 0--%) 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12