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s �I ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468.3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Jos ADDRESS AJ CRY21P ti CROSS STREET rEr4 ST S APN 01-3 - 2-1 PARCEL SIZE (J. [S C ��2 ��-e f f-C- PHONE OWNER NAME k-FrwJOE-,QSrI)I�NG(A-I� C7-Cz�-T ___ `G. OWNER ADDRESS PO 6())( 1-7-17 CIT//STATE21P �OQ E�S7� Cl'( 15353 CONTRACTOR / _ _fAd �+ 0 U��✓C/' PHONE CONTRACTOR ADDRESS / ®/'Nf/ -�w. Cm/STATE21P /y)o..� i_/.�, ?'r-j- LICENSE EC-42 CSC-36 OTHER NUMBER:71��-f,}�EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I- NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE li P REPLACEMENT C OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION OL-0 -fA.JIC— INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL L OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: 0 SEPTIC TANK TYPE/MFG CAPACrry Z D O gal #OF COMPARTMENTS 2 ❑ GREASE TRAP TYPE/MFG _ CAPACITY gal #OF COMPARTMENTS III DISTANCE TO NEAREST: WELL -!9-0� ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACHLINES0 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTERSED WIDTH ft LENGTH ft DEPTH It (� DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It .i DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE ft IL SUMPS WIDTH Lift LENGTH 'Z l= ft DEPTH 8 It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft q ❑ DISPOSALPONDS WIDTH .>c.+ It LENGTH ft DEPTH ft �C DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY UNE ft Q 0 SEEPAGE PITS NuMeER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION 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. MWIMUY04 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED Z TITLE_�{''j DATE I 1 rv' OE41Y AL I I � ��• I _,� �. _ •T �DEPART.M-EN.7 S.E.. N_LY_� Application Ac ed B - Date -12-12-VOIF Area Employee ID# `s� Final Inspection Date / �� SPECIAL PERMIT-A roved by Character of Solt to Depth of 3 t: PiUSump Soil CQracter. COMMENTS 0 L-a [-,O?—01= Ie-deco," -.Ecl A-,L A,,!E.Q+ti(T "69-0 1/60 . G RS E.4 UA01i CODS-t,c� ZO J SI— 00 &'7--1 (&t T M r4 G(G r4�r1� TS ✓�f�/S PE SC Received Checldt! Amount Date Permit/ Invoice# Permit ID# Code INFO B as Remitted Service Request# 42f�—' 1(5 ! o �w 42-001 f5-x fj� li� /'� -� �y� 2 �T� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT '