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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 CALL (209) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM UATE ISSUEI JOB ADDRESS ^ ,, v� �//� ✓� Q L ,�C`ITY/ZIP I.� hL CA9�i' C4 CROSS STREET ►y�f ~/I P�'j•�)� 12 c (� APN 0 ` - y FO I " �% PARC EOL SIZE (�� 9 OWNER NAME • a u 1 ✓ Q V i .7 I �) �(.� �� f �I� PHONE OWNER ADDRESS %�•+I �L!I��F. I�, > p CITY/STATEIZIPa L"OOH^1�'9 ^ S-,2 go yy� CONTRACTOR p 1 lC- QQ��i VIre-_e-S �%1.�G(,.® PHONE 7/b LpJ yLp CONTRACTOR ADDRESS �® 15 0 A -5'464? CITY/STATEIZIP 01 � �� CA { SIU ( LICENSE C-42 C•36 OTHER , A NUMBER /®�,`_�. ��EXPIRATION DATE_ 31 " ZD L WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # _ TYPE OF WORK: NEW INSTALLATION ENGINEER DESIGNED /AtTERNATIVE X REPLACEMENT L. K OUT -OF -SERVICE SEPTIC SYSTEM X DESTRUCTION 7 L! A INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: _ 3 NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG 7 CAPACITY I'Z(9 O gal # OF COMPARTMENTS, Z ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMEN-S DISTANCE TO NEAREST: WELL It FOUNDATION it PROPERTY LINE ft ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKG TX PLANT U SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES It Permit ID# DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH It LENGTH ft DEPTH It DISTANCE TO NEAREST WELL _ ft FOUNDATION _ ft PROPERTY LINE _ ft ❑ MOUNDED WIDTH - It LENGTH ft DEPTH 1t DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH it DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE f: 1 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 HOUR AQVANCE NOTICE REQUIRED FORP ONS - CALL 9553- 7 SIGNED //CT TITLE P— 02 I ' 7 DATE Z — i (- — Z4L;)7— L Final Inspection By (Yc..1(; S l � CLEi�.'a >Yu-: � Date `1 I 'I 17 L SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS 0'(A—}F'J"^)1YC1, PE Code SC INFO Received Check## Amount B Cash Remitted D to Permit/ Invoice # Se ice Requer# Permit ID# H;()(-' JLS 3vp +� ILI n 4/14/ , /' ' / 14 �� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14116 i --Il LLL...��