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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COU14TY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 96202 • (209) 468.3420 NoN-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP l.. t •'S'P eV4 '��Jy CROSS STREET 1• s- r4Dn�<5 � _APN 1�� /�-C,+�� PARCELSIZE L7 DWNER NAMEC i/liG S -D �' PHONE OWNER ADDRESS 44c .AA.� CITY/STATE/ZIP CONTRACTOR �{V L 1 f -'L I /� 16 �'�I� �'D -� Ado ^ PHONE � CONTRACTOR ADDRESS , l �. �jg «'(L �UY'L, /+y'�✓`�^ CITYISTATEIZIP ��- /"�' `� 7iI LICENSE 4IC•42 [70-36 OTHER ti NUMBER �✓Ju EXPIRATION DATE _ )i r� WATER TABLE DEPTH: 1l ❑ PERC TEST # C TYPE OF WORK: NEW INSTALLATION REPLACEMENT GEOGRAPHICAL INFORMATION: COOrdindte3 X Y INSTALLATION WILL SERVE: ❑ RESIDENCE Un COMMERCIAL NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: USE APPLICATION SEPTIC SYSTEM �, DESTRUCTION Q OTHER NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG P'1 V^ CAPACITY (�-i]Ll gal #OF COMPARTMENTS_ ❑ GREASETRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE it 4 LIFTSTATION SIZE TYPEOF PUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I/FILTERBED WIDTH ! R LENGTH �� ft DEPTH_! R fl DISTANCE TO NEAREST WELL o , Ir ft FOUNDATION V's ft PROPERTY LINE •51 tt ❑ MOUNDED WIDTH ft LENGTH ft DEPTH R DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE n ❑ SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ❑ DISPOSAL PONDS WIDTH DISTANCE TO NEAREST LENGTH ft ft FOUNDATION it WELL ft FpUNDATION ❑ SEEPAGE PITS NUMBER WIDTH ' DISTANCE TO NEAREST WELL ft FOUNDATION HEREBY n PROPERTY LINE ff DEPTH n ft PROPERTY LINE n DEPTH ft PROPERTY LINE I CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JDAOUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. SIGNED 'UR IIYJ!'Cli SC I IV1YJ ' rLCMJG L.HLL t LVJJ Invoice # .1 JJ�r V.7/ SIGNED 'UR IIYJ!'Cli SC I IV1YJ ' rLCMJG L.HLL t LVJJ Invoice # .1 JJ�r V.7/ INFO B Cash Romittod 5ervlco Re uest # __ DEPARTMENT •S ONLY Application Accepted By --_gate .�- �'" Area Emplo-rryee ID# � � �� Final Inspection By 3 .t 1- -. /�10ate -4 ❑ SPECIAL PEW" �I d ed by Character of Solt to pth Ft:z.> P&Sump Soil Character: RECEIVE flef 14 PE 42-01 SC Received ChgLItfII- ` Amount Date PermiU Invoice # Permit IDI! Code INFO B Cash Romittod 5ervlco Re uest # ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 9/21/10