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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 +I CALL 209 953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED 4 JOB ADDRESS 1 6(o O E b A C-T• CIN �p/ZIP I r-fyc- f 3 o+ CROSS STREET KoS QTE(l p. y}-,l APN SSS- PARCEL SIZE 1' I �• p OWNER NAME "'� • �` 1 ,' y PHONE (099- 9-9 OWNER ADDRESSS P(M CITY/STATEIZIP7 CONTRACTOR L-)'r,/c O tNy— ��0�"'�`��'��—V N m�'N'I '" PHONE 3 1"1- CONTRACTOR ADDRESS 40-T w• 01N14-- '' CIN/STATEIZIP I� C A 9 ?-4z) LICENSE C-42 _C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # FEIUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE I 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 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 LEACHING CHAMBERS #OF LINES LENGTH OF LINES It DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft IAI DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft `q- -�• ❑ MOUNDED WIDTH ft LENGTH It DEPTH It DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft `® ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE �1 o9n ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH O^QV� Ia DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE F.t� ROq/ME OUN7 L3SEEPAGE PITS NUMBER WIDTH ft DEPTH ft RTTqt DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft Ml�/yT 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. INIMU OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 CL SIGNED r � TITLE O NS✓LI AW 1 DATE J 3 1 kj d ARTMENT �NLLY Application Accepted By Date 2-- Area loyee ID# Final Inspection By Date 11 SPEC L PERMIT- proved by Character of Soil to Dem� of 3 t: Pi Sump it haracter: COMMENTS 5,37 l VC PE SC Received hec Amount Date Permit/ Invoice# Permit ID# Code INFO By ash Remitted Service Re uest 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT