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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS �c C•5Z� . V I S Z CITY/ZIP '(--il 1APN •� CIE-C, '3 PARCELSIZE CROSS STREET �'• '{- r 1 1 IU N� Fel WL'k- 7i 1 L I N l-1� PHONE ^ • OWNER NAME ` r 1-.•.v-o l L IN e1 S 2'�f,L Z 10 OWNERADDRESS 7�IU v�w I> CITY/STATEIZIP r7 ,r `- CONTRACTOR � I V� G' �' (i OF r J'II F-P� J I Vl C–r-T 1 p\L-- PHONE 7(✓ I C >� 1 C.� CONTRACTOR ADDRESS �V•} LA� �� ~' I CITY/STATE/ZIP I ��( C a LICENSE QC-42 OC-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # ( BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ 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 DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) • #OF LINES LENGTH OF LINES ft ❑ LEACH LINES ❑ LEACHING CHAMBERS ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft DEPTH ft ❑ MOUNDED WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft DEPTH ft ❑ SUMPS WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ft DEPTH ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE • ❑ SEEPAGE PITS NUMBER ft DEPTH ft WIDTH ft DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE I HEREBY CERTIFY THAT I HAVE PREPARES AWES APPSLICATION AND THE AND RULES AND WORKREGULILL BE DONE ONS OF SAN N ALCORAQUIN ANCE WITH SAN JOAQUIN COUNTY ORDINANCES, ATE t�IMUM 24 HOgR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 TITLE C`.�'�'Sy L'-TY•�T'7� I DATE SIGNED _ N.DD•9'YL_ 66,66' I I i aitL ilia I YjvQ 7 j � I I I Ij I O�o0yo! ZIP, �® I I 1 1 ' ti�_ ISOOI• � i �p�2 OG 4I L 1� y,. � t1 B}bnl' NN16� '5';I bblol •`� �� ,__ ft/y1NG6� gl• I I8 ..f•3� �/ p �---�es,.00'- U ins�b• --'� 3 � D7•yT I I _°j •• •• croMl. `tel VIN2 2 I DEPARTMENT USE ONLY- Application NLYApplication Accepted By Date Q��u^ l Area Employee ID# Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS - • PE SC Received Check#I Amount Date Permit/ Invoice# Permit ID# Service Request Code INFO Cash Remitted ONSITE WASTEWATER TRTMNT SYSTEM PERMIT n�_n.