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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 C y CALL 209 953-776997 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS 4035- %,). 5 • 1QNL61r)6E YJ!z. • CITY/ZIP I JZ,'�-C_ 0 v' A p�' 2 �y �J LL `'y CROSS STREET �L�'`1,j T- L/-�I N t y APN 7 �ly�2 TQ - 1 1 GPARCEL SIZE `I' TC1 `\C`,•, p OWNERNAME A t-E_)ANAP-o A -Avv%%LLA I�z MPHONE I-ZC�Js . OWNER ADDRESS -,t` / W ' �TbNG.r't )&e o,~ CITY/STATE/ZIP �l � �+ r 1 CONTRACTOR LIVE Q `T'1r OgE//J Vl o�N 11'l t'�Ji ACL PHONE 3&1_03 ,/ 7 p '15 CONTRACTOR ADDRESS W O' •1� 5- 1 CITY/STATE/ZIP V o D, c t% 2-q 0 LICENSE C-42 L.0-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE - REPLACEMENT II 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 TYPEIMFG 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 LEACHING CHAMBERS #OF LINES LENGTH OF LINES DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE Y�\ ❑ FILTER BED WIDTH ft LENGTH It DEPTH DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ,I [3 MOUNDED / [3 SUMPS ft � MOUNDED WIDTH ft LENGTH DEPTH A/@ v o DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE yq��ft 3 /4o SUMPS WIDTH LENGTH DEPTH ••• It`� O•V DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE��Q�y� ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH .._ DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE 'tl ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft MFHT 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 24 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 a SIGNED /v L TITLE C_ONSV✓l-`M wJT DATE �j -1 EPARTME 'AT)h O ILY Application Accepted By Date Area Employee ID# Final Inspection By Date SPE IAL PERMIT-Approved by Character of Soil to opt of 3 Ft: it/S p Soil Character: COMMENTS ' r 6to ryunl[o PE SC Receivedh Amount Permit/Code INFO B as emitted Date Service Request# Invoice# Permit ID# Z S 313 I � 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT