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Th4'\ yCaxn II' Dai' 0.,A— ONSITE --ASTEWATER TREATMENT SYSTEM .3MIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697FORINSPEC77ONS EXPIRES 1 YEAR FROM DATE ISSUED v JOB ADDRESS - �_.�_ ,_�.C�I(T�Y/ZIP_ 0.71 � CROSS STREET _./,�/�,, -- _ _.. _ _ -_ APN _�["� �C _ _ - —. P �JCEL S¢E f/T Y OWNER NAME G Tom' r. V _ _ _ __._. PNOID�/ -,,9O OWNER ADDRESS CrTY/STATE/ZIP \=1=��J1 r - _ CONTRACTOR V ._____ PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE L C42 IJ C-36 OTHER NUMBER EXPIRATION DATE_ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y_ 1 PERC TEST M BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITIONENGINEER DESIGI D/ALTE NATIV r1 C Code INFO B REPLACEMENT V -/OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION V e c .t INSTALLATION WILL SERVE: ESIDENCE LI COMMERCIAL 11 OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: _ ❑ SEPTIC TANK TYPEIMFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY _ gal # OF COMPARTMENTS-- OMPARTMENTS_DISTANCE DISTANCETO NEAREST: WELL It FOUNDATION it PROPERTY LINE fl ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES R 4/24/12 DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE it ❑ FILTER BED WIDTH It LENGTH it DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION it PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH It DEPTH _ It DISTANCE TO NEAREST WELL K FOUNDATION ft PROPERTY LINE It ❑ SUMPS WIDTH ft LENGTH it DEPTH ft DISTANCE To NEAREST WELL--- It FOUNDATION _ _ _ it PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE _ 11 ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH. h DISTANCE TO NEAREST W ELL it FOUNDATION N PROPERTY LINE it I HEREBY CERTIFY THAT 1 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. MIN/ R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED _. _ ______ _ TITLE DATE Application Accepted Date, Area Employee ID#� Final Inspection B — Date L 1 SPECIAL PERMIT -Approved by Character of Soil to eq of 3 Ft: Pi um Soil Character: COMMENTS 11(1 � /./ASS �D L�- f - /d P Guts PE SC Received Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO B Cash Remitted Service Request # S ,2 CD6 6 � / fs�(�: Gu'7� j .UD t'r�l CEzC - f•C.s�. 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24/12