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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 1, CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS 2,d- JC lid 2�— CITY/ZIP 57Oe/c 7-0N 4sZob CROSS STREET T/'F_R TI[.ICNTj¢ APN 17 '- O G PARCEL SIZE p / C! OWNER NAME eRc>&"'s 0-7 tt ll ly I r y ��ttJt�c1 F t�PHONE �4^ �i�` —63q9 OWNER ADDRESS `to 6' OO> ( II/'j •1 CITY/STATEJZIP'-!�C1G?l:�N C.'A Zd - CONTRACTOR C ds►ICAI-N—, CSP PHONE S59- 2 Q f- D 776 CONTRACTORADDRESS.:S F S N urLo cTSj'K /d/ CITY/STATE/ZIP :F�U%/C r_4• '7 7 2 7 LICENSE 0 C-42 O C-36 OTHER 6 NUMBER777InL EXPIRATION DATE ' WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y O PERC TEST,, # BUILDING PERMIT# O D USE APPLICATION# - .TYPEOFWORK. NEWINSTALLATION ,,, O REPAIR/ADDITION LI ENGINEER DESIGNED/ALTERNATIVE .,10 REPLACEMENT O DESTRUCTION T jINSTALLATION WELL SERVE: 'IQ RESIDENCE' O COMMERCIAL. _ .GIy OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: i NUMBER OF EMPLOYEES:' j O�'SEPTIC TANK •TYPEMIFG 1'' CAPACITY gal #OF COMPARTMENTS Ia' GREASE TRAP 7YPP/MFG�J 7L f/�J CAPACrrY /S a O gal #OF CO.�ARTMENTS Z r ua 1 „ , , I . 'DISTANCETO NEAREST: WELL S'O-1- ft FOUNDATION ft. PROPERTY LINE .. R •O LIFT STATION- SIZE• TYPE OP PUMP O PKG TX SAND OIL SEPARATOR(ENCLOSED SYSTEM) O LEACH LINES... Or LEACHINGCHAMBERS - #OF LINES ••.LENGTH OFLINES.. ••-'DISTANCE TO NEAREST •WELL- - ft FOUNDATION PROPERTY LINE ft O FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LATE R A� O MOUNDED WIDTH ft LENGTH ft DEPTH ft 10_ ' DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE R frn^ O SUMPS WIDTH ft LENGTH ft DEPTH ft r J DISTANCE TO NEAREST • .WELL - ...ft FOUNDATION, R PROPERTY LINE R 0 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft . -DISTANCE TO NEAREST.. '-WELL •'F�• ft.'FOUNDATION�" ft PROPERTY LINE �• ft I ' O SEEPAGE PITS NUMBER WIDTH ft DEPTH I 1�1•'E r'� ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 'ft I HEREBY CERTIFY THAT I VEP PARED THIS APPLICATION AND THE WORK WILL BE DOPE IN ACCORDANCE WITH SAN JOAQUIN COUNTY,_I `� IN CES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUM OU�DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 `• /'"'�"' I 'SIGNED TITLE S r.PTit IC A/7 ff-NM) DATE 1 FUJI i I 1 O M T D I DEPARTMENT U ELY Application Accepted ' - Date ( "f O �'M. - Employee ID# _7'3 79 �Q9 Final Inspection Date / 0.SPECIAL PERMIT-Approved by 'Character of Soil to Depth of 3 Ft PI&ump Soil Character: COMMENTS PE SC Received Check#/ Amount Permit/ Code INFO B Cash Remitted Date /�Service Request -7# - Invoice# Pervdt M#00.01) I O 15(ZD S Z /a- 42-01 42-01 )J�LvM- p Lq ONSITE WASTEWATER PERMIT 05/30/2007