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w ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 NON-REFUNDAB E PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS O , CITY/ZIPzia!�!ZQ - CROSS STREET �^ ' )i ` ^, APN Z Q'5'ZDV L 11A PARCEL SIZE 611-jr, a O c v OWNER NAME PHONE a OWNER ADDRESS 4F?-0 10 j,TYS&4 TSE CITY/STATE/ZIP /��►l f�/��Wim/ CONTRACTOR 10 Q w r)y,l`tln\ PHONE MIA) IA - 1111 / CONTRACTOR ADDRESS 1 I� 9 NLa K k- � )l CITY/STATE/LP C71�1l�JX LI.-C-42 ❑ LICENSE ..:C-36 OTHER NUMBER` EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ING PERMIT# LAND USE APPLICATION# PERC TEST # Fau-ILD TYPE OF WORK: -T NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE I REPLACEMENT IJ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER 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 MCr DISTANCE TO NEAREST: WELL It FOUNDATION R PROPERTY LINE T ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) EI V�D AVG ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft 12019 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE — JO /H.. IJ ❑ FILTER BED WIDTH ft LENGTH It DEPTHN��ryVIRtlYtrUi L,OUN7Y DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ��N pip FNT,4C L3MOUNDED WIDTH It LENGTH It DEPTH ft TMENT DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It L3SUMPS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE It ElDISPOSAL PONDS WIDTH It LENGTH R DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTYLINE 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 48 HQq9 ADVANCE NOTICE RE IRED FOR IN PE TI N -PLEA E CALL 2 953-/7697 SIGNED TITLE 1 DATE d ARTMEN U I VNL Application Accepted By Date t Area Employee ID# Final Inspection Bye Date_ SPELL PERMIT-Approved by Character of Soil tO,Dep of 3 Ft (- i Su RS it Character: II COMMENTS_ pt�-� I n 'r f 1 jL 111/✓ PE SC Received Checkkt/ Amount PermiU Code INFO Cash emitted Date Service Request# Invoice# Permit ID# R 0°I 1 42-01 _ �/�y��I/1�,C� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14118