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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 • NON-REFUNDABLE(PERMIT / ^� CAALL 2099)9953-7697 FOR INSPECTIONS p EXPIRES 1 YEAR FROM LATE ISSUED JOB ADDRESS �1 ZI 'L,wryF�'�njAJE F`y- CITY/ZIP I '�, I�y 1 3�� EL CROSS STREET 1 , n V APN -2-,+k- �b ��T PARCEL SIZE � I A..�" - o p.�y� 0 OWNER NAME QL ✓�r 1��r�,,�p��" /� .f-PHO�NEE OWNER ADDRESS c1 w wF-$2.a INF. i�J CITY/STATE/ZIP 1 P- 1"�y� ��T CONTRACTOR L'I ife `�,�K' &eMkj✓I1e-D'*jmEAPHONE 3/ar7-03_'s CONTRACTOR ADDRESS ' � .ST' CITYISTATEIZIP L-M i c A 9SS-2-40 LICENSE i C-42 C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # FEUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: = NEW INSTALLATION c REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE .5 REPLACEMENT .J DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE I. 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 ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES D LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER 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. INIMUM Z4A DUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED /°-tel TITLE 4-e'/VSy4-F^PIJ7 DATE I✓ 4�MFNr ��VFo _Oi1111 r: -F-17 �D ARTMENT NL /� Application Accepted D to Area ` Employee ID# Final Inspection By Date SPE ALP MIT-Approved by Character of Soil to D pth of 3 Ft: Pi ump Soil Character: COMMENTS PE SC ReceivedkeW Amount t/ Invoice# Permit ID# Code INFO Cash Remitted Date Service Re uest# kA +Q-i 0 42-Ot ONSITE WASTEWATER TRTMNT SYSTEM PERMIT