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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAX JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 3M E WEBER AVE-3"'FL-STOCKTON CA 95202 -(209)468-3420 „ t NON-REFUND IIT CALL(209)953-7697 FOR INSPECTIOMS EXPIRES-1 YEAR FROM DATE ISSUED Vl, JOB ADDRESS CITY/ZIP X57` OF' Ai PIN G P -080" 50 I CROSS STREET APN PARCEL SIZE of rt NE 3 I--OF OWNER NAME PHONE--.., OWNER ADDRESS ��-A.{-"(//�/�•�f��I`�1' CITYlSTA7E/ZI O—/'J� q,52-1 � ,S CONTRACTOR P ~""-aLs- )! 1• 111L111��/t�� PHONE 1 Y ///�� CONTRACTO`RR AADDRESS ' *- l�_�rfy�. L(^CyIITY�YISTATFJZIP ! LICENSE N C-42 Cl C-36 OTHER A 6�w & •'6r NUMBER 1 vv, 1 _ EXPIRATION DATE O I WATER TABLE DEPTII: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# TYPE OF WORK: NEWINSTALLATION REPAIRIADDITION ❑ ENGINEEERDESIG /ALTERNATIVE REPLACEMENT DESTRUCTION OLD INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER 1 NUMBER OF LIVING UMTS: / 4 NUJIBER OF BEDROOMS: NUMBEROFEMPLOYEES: SEPTIC TANK TYPE/MFGG 1 CAPACTrY gal #OF COMPARTMENTS j ❑ GREASE TRAP TYPUMFG CAPACITY gal #OFCOMPARTMENTS ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION 5 ft PROPERTY LINE fith ❑ LIFT STATION SIZE TYPE OFFPPump �]L4 L3 SAND OIL SEPARATOR(ENCLOSED SYSTEM) \%v LEACH LINES )(LEACHING CHAMBERS ✓ � a #OF LINES LENGTH OF LINES /J�4 R Aj DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE f.16 O FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ti D MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE'fO i/.:REST WELL ft FOUNDATI N ft PROPERTY LINE R SUMPS WIDTH �+ ft Le1iGSiW1 _ R DEPTH I1? DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH _ft DISTANCETONEAREST WELL ft FOUNDATION R PROPERTY LME ft ❑ SEEPAGE PITS WIU77I _ft LENGTH ft DEPTH tt DISTANCETO NEAREST WELL R FOUNDATION ft PROPERTY LINE tl I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, 1 STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQVIN COUNTY. (5.�� Iy1NIMU 4 NOTICE REQUIRED FO �l�Cl'b\I 'S-P�, F.CALL(209)953-7697 SIGNED �l TITL I�tTVIYAYIyAV//Ul/' DATE ru NMIET- M,F r r E I I � C i r LL I DEPARTME/NT .'E ONLY Application Accepted By Date ( / .7 Areay{ Employee ID# M W. Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soll to p�l a1f 3�'t Pit/Sump Soil Chnracter: i COMMENTS PE SC Received Ch Amount Permit) f ode INFO EIV Cash Rcinitted Date Service Request# Invoice# Permit ID# o1;71103 42•W•001 ONSITE WASTEWATER PERMIT IF 12/2/02