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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 n �,y,�L.ALL ZCU`J yet) ,-5-/Uy/ FOR INSPECTIONS tXPIRESQ IIt;-;()'+ TEAR FROM UA IE ISSUtl JOB ADDRESS ZQO�}a- tzz` �-r>qP- �r'C✓.1 1 ER-rzz �f CITYIZIP -I� ` J� T CROSS STREET w - I , `` Interim APNy5 S- Zfy - 0+ PARCEL SIZE �• OWNER NAME KAcjS E2 94�NC'N f L -L -C PHONEE� (010 - ''74S"160-5 r`TLS )2 P. OWNER ADDRESS ' O , Y a /' � CITY/STATE/ZIP 094� t>A. CA I TS"5 CONTRACTOR L4\)C O& -IL GE0E-W19z'JrAE&tn\L- PHONE 3(o`►— 0' W CONTRACTOR ADDRESS '-+O-3L tN • O C - &I-- CITY/STATE/ZIP L -M( CA - / Z"lL0 LICENSE C-42 C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y X PERC TEST # BUILDING PERMIT # # OF LINES LENGTH OF LINES LAND USE APPLICATION #')P+ TYPE OF WORK: - NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE ft DEPTH REPLACEMENT DESTRUCTION INSTALLATION WILL SERVE: _. RESIDENCE I COMMERCIAL OTHER It DEPTH 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 ft DEPTH 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 DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH It DEPTH DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH It DEPTH DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ❑ 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. MINIM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 (� -0,A) 5-z( - I SIGNED TITLE G0 "I DATE O Application Accepted By Final Inspection By Character of Soil to Depth of 3 COMMENTS -Cor M4 Area V ` Employee ID - SPECIAL PERMIT - Approved by Character - PE SC Received Amount Date Permit/Invoice # Permit ID# Code INFO B Cash Remitted Service Request # 5Z l5S l az-ot ft It It It It It It It It It It It ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 2 2 o gV 2 1 � J24e Cy p dt/ 0= r 3'9:� m/. )