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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 NON-KEFUNDABLE PERMIT UALL/�ZU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS �C E• .�-� 1 � F -F !"� • CITY/ZIP A t�P6 qS 2 -A -D �}�, CROSS STREET ✓y.S*T I� M•� APNT W -1 G�� - 0SV - 41 PARCEL SIZE �� • OWNER NAME 1y1y,, N61,1) T� ` 6"i1C'MLA4-1 A PHONE 67-15 - -lZZ3 OWNER ADDRESS ■ MOUNDED CRY/STATE/ZIPP� LENGTH ft DEPTH CONTRACTOR L -%QC G�DF��I(��►�o-N �'►'1�TIf�L PHONE 749-03^1�- �OAK. CONTRACTOR ADDRESS T+� UJ t CIN/STATE/ZIP wpb% C^q 1 S-2'*0 LICENSE I ,C-42 I .0-36 OTHER NUMBER EXPIRATION DATE 'I WATER TABLE DEPTH: V ft GEOGRAPHICAL INFORMATION: Coordinates X Y X PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: a NEW INSTALLATION L: REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE D REPLACEMENT la DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE 1-1 COMMERCIAL I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL It FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ■ LEACH LINES I I LEACHING CHAMBERS # OF OF DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY ■ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE To NEAREST WELL- ft FOUNDATION It PROPERTY LINE ■ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE To NEAREST WELL ft FOUNDATION It PROPERTY LINE ■ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE To NEAREST WELL- ft •• • PROPERTY DISPOSAL • . DEPTH DISTANCE To NEAREST WELL ft FOUNDATION PROPERTY ■ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE To NEAREST WELL It FOUNDATION -ft PROPERTY LINE 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. M NIMUM ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 04An 5 -1 Of SIGNED TITLE DATE ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■ii■lee■■ri7 ■!■��■■■ISI©R■■■I!1!■■■■■■■■©�Q7Il�®QI�J ■■■■■iii■11'J■■ fell ■■��11■■R!'il■Y!!�C ii■■■■■■■■■C�`1��I�� ■■■■' 7�lil�■■■IAI■■■■IIEi■1■Rik►�!■r■■■■■■■■■■■41::L�lli1l=l��ul ■■■■■■■■■■■[`!■■■■11■■■■fir■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■rim■�i ■I�■■■r■��1!1!A"!■■■�■��■■■■■GJ■■■■■■■ 09310% W PE SCReceived Check#/ Amount Date Permit/ Invoice # Permit IDN Code INFO By Cash Remitted Service Re uest # N5110 - I 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT