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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 I ION-KEFUNDABLE F•ERMIT CALL} ZUyISSUE FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSU JOB ADDRESS Z o -+ o 3 %j + Ct-u o TT 1 p ��,,. CITY21P Lc CK C F oO-c, Gl S -Z3 71 CROSS STREET /LL I t U(ZC4- ST- �y� p A�PNp0 +� I � 24 �� hyy-r��,� L PARCEL ,,SIZE 2' I .' r� AC OWNER NAME TiL CE:'1- L�Ni�1—t, PcTE- -s VIV �.��,�12-A pUa /'"" p"HANE �G(� -403- C17-7-31 T1S4 OWNER ADDRESS �� X ro�l-o �oa33 . it ATE/ZIP �L'K-%E''r�v✓.� i CA I7 -Z 71 CONTRACTOR Ny� O(� G-E0EN%jj P-0fQWIE&fT(AL PHONE 3(PC) -03 1 J / CONTRACTOR ADDRESS A40 -3-W ` �' ST-. � - CITY/STATE/ZIP ✓ ( CA _r pZ'T 0 LICENSE ;C-42 .0-36 OTHER NUMBER EXPIRATION WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE -� REPLACEMENT DESTRUCTION INSTALLATION WILL SERVE: -1 RESIDENCE COMMERCIAL 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 ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SANJOAQUINCOUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMU ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953.7697 SIGNED /HOUR 'l TITLE C J NfVLT f�N � DATE 3-2-0-19 ------------------------------ M9 VFO TyD pMF'Voo rY '9R I -, DEPARTMENT SE O Y Application Accepted By Date Area Employee ID# Final Inspection By Date SPECIAL P RMIT - Approved by Character of Soil to De of 3 t' / Pit/Sump Scyl Char COMMENTS - • Z / i. K 7 PE SC Received K-`Ch—ecW Amount Date Permit/ Invoice # Permit ID# Code INFO B Remitteld Service Request # Sz /Z"Of M 00 7Y'70-11 42-Ot ONSITE WASTEWATER TRTMNT SYSTEM PERMIT