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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 CALL(209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 2-a CITY/ZIP 1-ttzgj'.PI "�j C•5-irQo Z' s CROSS STREETSAC�mSIV T� APN O O I- 2-00 - 9 1 -PARCEL SIZEV 1, � OWNER NAME Da2011" Y .A<p-11� 0A1AUr---tj'j PHONE 731- j � Ho OWNER ADDRESS 6�./�r !�p'��/ W'�j1LM7 r I�TATE/ZIP 'T�neo QN CA CONTRACTOR UV` oAY— t'MwZ0NV"E^jTAt, PHONE 3(0ci- 03-4;- CONTRACTOR ADDRESS 4o-4 GJ. .ST- CITY/STATE/ZIP L-CrD 1. CA q S Z--4 0 LICENSE LC-42 I C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y K PERC TEST # � BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT - DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE I COMMERCIAL I 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 E LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH It 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 It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It 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�'/A��IOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 G: SIGNED /— TITLE DATE Pj4 ILL Fi�Fr O �vN '9l ry FNr DEPARTMENT ED L( �AL Application Accepted By ate AreaEmployee ID#Final Inspection By ` Date .I $PEIT-Approved by Character of Soil to Depth of 3 Ft: PWS' ' Soil Character: COMMENTS'/�2 ��,f�•i �?'� /i'Y/� PE SC Received heck#/ Amount Date Permit/ Invoice# Permit ID# Code I F B Remitted Service Re uest# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT