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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-REFUNDABLE PERMIT /� SCALL 2t09/95533-7697 FOR INSPECTIONS /� A�ExPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1(a m" W• &9A r tr{i` R-b- CITY/ZIP CROSS STREET -h�rNSE7J APN -! " ' 0 `OT PARCEL SIZE p Z� 2 0 OWNER NAME A36-1 KV f tom PHONE 5j C)-938-3 b-j� OWNER ADDRESS 4 ao Ar-or lAyjM ,,..��p.� CITY/STATE/ZIP �I�k'YYIOr.sY� C •7�)� CONTRACTOR LIVE O� &t-0G-NV1�NrACN •r" PHONE 3ig ��7 q CONTRACTOR ADDRESS 1V-4 W. OAA— �• CITY/STATE/ZIP Lot>( CA LICENSE I IC-42 UC-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST #___L_ I BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAWADDITION CI ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT i. 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) ❑ LEACH LINES L LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE AA ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE A ❑ MOUNDED WIDTH ft LENGTH It DEPTH 64. ft `O DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH It DEPTH S�]�.. ft tog DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH •TEdr R(�r CQU DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE FNTjq� ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft RrMFNT DISTANCE TO NEAREST WELL It 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. INIMUM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 2 4 SIGNED TITLE LO/`IS�- DATE -� 1 V`I ARTMENT S O LY Application Accepted B Date Area Employee ID# Final Inspection By Date LJ SPE IAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received Amount Date Permit/ Invoice# Permit ID# Code INFO 13Y ash Remitted Service Re uest# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT