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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS } ,r}�EXPIRE+S I YEAR FROM DATE ISSUED JOB ADDRESS11`400 CITYIZIPL �� 9-5��_ _ ii a CROSS STREET APN '�PAARRjCEL SIZE O OWNER NAP7E f.. 5VN E LAIYQ (/ [ fJC&PK GA IIONE!moi' - -W-3113 �•� rA __ ` /// a 2 �/� /J OWNER ADDRESS 5490 F�51 69 syn 616c-14 9b— CITYISTATEIZIP L[012 I -GAS " :i CONTRACTOR DA. �,,�+,f�� ,d�,r �JI�JI ,] �fIW C, PHONE T� CONTRACTOR ADDRESS �V. 1;i1� L Ci*J WAV CITY)STATEIZ,IIAr - LICEItiSEA C-42 ❑C-3b +OTHE � C-� R NUMBER 1� EXPIRATION DATE � -03 � WATERTABLEDEPTH:7� _ � 2 A,/ -ft GEOGRAPHICAL INFORMATION: Coordinates X Y _ J ❑—PE—RC TEST(S) NUMBER LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER bL'St4N�EI)///ALLTEyR`N�ATIVE RE:PLACENIENT DESTRUCTION INSTALLATION WILL SERVE: Cl RESIDENCE COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPEIMFG6 vc- w aYACITY gal 4 OF COMPARTMENTS 3 ❑ CREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION f. PROPERTY LINE R ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) E�rt: Ci �t _ LEACH LINES ACHING CHAMB L1 r� #of LINES LENGTH of LINES 75` ft DISTANCE TO NEAREST WELL -_ft FOUNDATION 6 ft PROPERTY LINE I , tl ❑ FILTER BED WIDTH fl LENGTH it DEPrH ft DISTANCE TO NEAREST WELL _ —ft FOUNDATION fl PROPER7Y LINE tZ ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION i ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH _ ft DEPTH_ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft XSEEPAGE PITS WIDTH ft LENGTH A ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUIX'DATION I j• )- ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANI)THE WORT;kVILL$E DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MI UM U HO VANCE NOTICE REQUIRFD FOR 1r 1: TIONS-PASE CALL(209)953-7697 42- dfE ��iiSiGNE TITLED DATE - J I I j r _ I • - _ _ � I rCOO 5.1 �-` . _ 1 4. } -4 - - iI`I Aj - i. JI 1 1 IN _ - y Application Accepted By. F/ / Date of Area .2[ Employee iD#-� Final inspection By Date _f ❑ SPECIAL PERMIT-AQproved by Character of Soil to Depth of Ft: Pit/Sump Soil Character: COMMENTS' S C r !�=` � .s" en,/rt. - 4r PE SC Received �Chec Amount Permit Code INFO B ash Remitted Date Service Re ucst# Invoice# Permit ID# 4L.11 a; 42-01-401 000 gI11DP1�lI L S00Aj>F`1'I=::: 2+700 3( ,2-2-5 607' bgi�pNS{TE WASTEWATER PERMIT