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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT /aj/� SAN JOAOIAN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468.3420 NON-REFUNDABLE PERMIT— CApLLj(209)953-7697FORINSPEC77ONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS ... - ...--.._. __.._. ......__'- "----.............CITYIZIP,1.. oeJ It 7 PARCEL SIZE _ _.__._...___ o CROSS STREET•I.LW._ 3�,L..._._...._........ APN.............1........... -...._..._..__......_ _ x OWNER NAM :_ 1 �LrnW�i .Atr��_..._._....._... _......... ............._._...___........._.._._.._......PHONE }OWNER ADDRESS�.me..............__ _-A'�'�J.1.LY`�!- CITY/STATE21P CONTRACTOR..ISomt-owa. Sr3'{ -....__.._._...._._____.PHONES- .�- CONTRACTOR ADDRESS ...... .-..--------------............_................__CITYISTATEMP__.. LICENSE l..iC-42 L., C-36 OTHER.,_.......__. _. NUMBER.... ..._...... EXPIRATION DATE......__.... ._...__-......_.._.._._._. ....-.-.� J�amj. L WATER TABLE DEPTH:-........._.. ft GEOGRAPHICAL INFORMATION: Coordinates _ [ BUILDING PERMIT#__-- LAND USE APPLICATION PERC TEST # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNE /AQ LTERNAT)VE REPLACEMENT ' T_--_Z Scu'�- OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION 1. 6 r INSTALLATION WILL SERVE: I RESIDENCE i_i COMMERCIAL 1 OTHER--...__._._ NUMBER Of LIVING UNITS: NUMBER OF BEDROOMS!._..3' ..............._.__._.__.._ NUMBER OF EMPLOYEES:,-,......__,.y_,....,....t..-....__... SEPTIC TANK TYPE/MFG(jlj,�_ .,Q- -._.. CAPACITY>_2�5� ,, q., #OF COMPARTME -1_kNTS �LJ._.... ❑ 'GREASE TRAP TYPE/MFG ._..„.__.._.__-....--._..._ CAPACITY -_�.-. gal #OF COMPARTMF.NTS�-., DISTANCE TO NEAREST: WELL _. ft FOUNDATION_�?-._.__ IT PROPERTY LINE ❑ LIFT STATION SIZE -_.___._..TYPE OF PUMP____-,__.....❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS,.—.._._._-._._..._..-.._...__..._............. #Or LINES LENGTH OF LINES.__-____-.-_._.___.._..It DISTANCE TO NEAREST WELL-..._____.._.,. h FOUNDATION _-,-,�_It PROPERTY LINE .It FILTER BED WIDTH -._it LENGTH_- ft DEPTH--:3S ft -LOSS. DISTANCE TO NEAREST WELL SOk- 1t fOUNil:.li(Nl TT4 n PROPERTY LINE '�} It ft ❑ MOUNDED WIDTH_-_..._...._-..__..._._ ft LENGTH-_....._._.._.__. .__.__....__ft DISTANCE To NEAREST WELL �,It FOLINDA rION ft PROPERTY LINE_ _ft ❑ SUMPS WIDTH it LENGTH__-__._.... ft DEPTH.__-.._-.._._..-- -._--it DISTANCE TO NEAREST WELLIf FOUNOAtION--it PROPERTY LINE.-r it ❑ DISPOSAL PONDS WIDTH......................_........._..._..ft LENGTH-____._........._.__._ ft DEPTH._.. ---__-..--ft DISTANCE TO NEAREST WELL.,-....._.._ .it FOUNDATION-_,-.__._..--.._ft PROPERTY LINE ❑ SEEPAGE PITS NuMBER ._........._._............__..- DISTANCE TO NEAREST WELL___.._..........-_ it FOUNDATIOFI ,,,._••--_-.._._ft PROPERTY LINE _._..-It 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 24!-LOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE - Wn1P�✓=.�___...._�._.__.._. DATE.,3....`. =l6_..._.....---........._.. -r - La yY 7 121+ 1 !� _. .. ,1 nrzPARTM,9. T c Y � �ly z77 j5t Area .i1.2 _�i•�_.... Employoe ID _ � Appilcatian Accepted Bq _._ _ Final Inspection By._— -�te.-- - /¢ _ SPECIAL PERMIT-Approved by -- Character of Soil to I h of 3 Ft ---- / __ PiUSump Soil Character: `--•---- COMMENTS ;_-tl: �PE SC Received Check#/ Amount �- Permit! Invoice# Permit ID# n R Code INFO B Cash Remitted ate e uu.# Service_-..............._1___----T--- 'LtCffS ONSITE WASTEWAT2<�TH�MNT'ST'EM PERMIT ;124;2 Pil 'r2 0 9 2015 SAN JOAQUIN COUNTY iC_MTAl