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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 - (209) 466-3420 NUN-MIFUNDABLE PERMIT t ALL LU`J NJ0.5-/10y/ FOR INSPECTIONS tXPIRES T TEAR FROM UATE ISSUE( JOB ADDRESS 4 (4) (7 NQS c'�{\ V I S )� . CITY/Zip L_O D I "f5 2-L+7-- CROSS -L+ZCROSS STREET APN ¢�E z- & OWNERNAME Mf -Tr -r Sry VN/ hL-OcK- 7-1 V61NL9-' PHONE OWNER ADDRESS= I -?-U D CITY/STATE/ZIP 0 -01 F"� ey 2-14 CONTRACTOR UVt l go G EU E—p�y (R-�'N/ V>''1 t -N I �L— PHONE 3 VAI - C' " ) CONTRACTOR ADDRESS _ "-(o '} CITY/STATE/ZIP LVDI, (A LICENSE IC -42 I IC -36 OTHER NUMBER EXPIRATION DA WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # ( BUILDING PERMIT # NEAREST LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE NEAREST REPLACEMENT WIDTH DESTRUCTION INSTALLATION WILL SERVE: 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 NEAREST 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 WELL DISTANCE TO NEAREST ❑ FILTER BED WIDTH CO ENTS Zm DISTANCE TO NEAREST ❑ MOUNDED WIDTH PE SCReceived ft LENGTH DISTANCE TO NEAREST ❑ SUMPS WIDTH ft FOUNDATION DISTANCE TO NEAREST ❑ DISPOSAL PONDS WIDTH ft DISTANCE TO NEAREST ❑ SEEPAGE PITS NUMBER ft LENGTH DISTANCE TO NEAREST # OF LINES WELL It FOUNDATION Character of Soil to Depth f 3 ft LENGTH CO ENTS Zm ft WELL ft FOUNDATION PE SCReceived ft LENGTH Code INFO Cash ft WELL ft FOUNDATION ft LENGTH ft WELL ft FOUNDATION ft LENGTH ft WELL ft FOUNDATION _ WIDTH It WELL ft FOUNDATION LENGTH OF LINES ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH ft ft PROPERTY LINE ft DEPTH It ft PROPERTY LINE It DEPTH ft ft PROPERTY LINE It DEPTH It ft PROPERTY LINE ft 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. IMUM 24 qQJ4R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 / SIGNED TITLE C c•T�S� L l-Y�iT�T DATF r� —) L+ ( X eine' I I I I I I I Flo I y I I I I I (CJ NLV-d I p V1 e, I�_l-br-t4-+•L L -� _ _ _ _ _ _ _ _ _x._Dr.a• _ N. arum' w / I � 66103' � �� MOIRB Y11d5ar - p I I 'it .3c" I DB�AD' J h N. D1•N' ww I Application Accepted By Final Inspection By / Character of Soil to Depth f 3 : CO ENTS Zm PE SCReceived Checks Code INFO Cash �;-1 52-' j 15-2, G Date Date USE ONLY [� Area Z S i SPECIAL PERMIT Pit/Sump Soil Character: Employee ID# Approved by It w Q HE Remitted Date Service Re uest # Invoice # Permit ID# ONSITE WASTEWATER TRTMNT SYSTEM PERMIT