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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT 1�1 Op SAN JOAQUIN COUNTY EA14RONNIENT.AL HEALTH DEPARTNIEN-T 600 E MAIN STREET-STOCK'TON CA 95102-(209)468-3420 NUN-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOBADDRESS 2276 g /f SCS-sC(.!�_ r�L.� CFTY/ZIP CROSS STREET G/ r �'/ APN OL73-/70— O PARCEL 517,F. OWNER NAME PHONEY�r"L- J • t•�V'V'G sj0y¢ —o51 3 I �+ OWNER ADDRESS L5 L V11 �rA d�.�, j( r--,/ L � CI7Y/$TATElZIP �-n'L CONTRACTOR 12c 1-"7 PJ 1 t (G 1"L�61 11"i C_ PHONE %�4- —O CONTRACTOR ADDRESS—Awle— �J-r CITY/STATE/ZIP LICRNSE L) C42 LlC-36OTHER !� NuMBER OfO `i2 EI(PIRATION DATE iy0 /J, r WATER TABI-F.DEPTH: %� ft GEOGRAPHICAL INFORMATION: Coordinates X y ❑ PERC TEST # RUILDING PERMIT# fl LAND USE APPLICATION# D TYPE OF WORK: NEW INSTALLATION ❑ REPAIRJADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION �) INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: /� SEPTICTANK TYPE/MFG- L� CAPACITY gal #OF COMPARTMENTS A/ ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS �� DISTANCETONEAREST: WELL //%DCr ft FOUNDATION 5 If A PROPERTY LINE 4-t fl ❑ LIFT STATION SIZE TYPE OF PUMP (3 PKGTX PLANT ❑ SAND OIL SEPARATOR(]ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS #OF IJNES LENGTH OF LINES 1 Ob —ft I Ifi / DISTANCE TO NEAREST WELL ft FOUNDATION I Q ft PROPERTY LINE S 'f R ❑ FILTER BED W'mTB ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WmTH ft LENGTH _ _ft DEPTH ft DISTANCE TO NEAREST WELL �ftP�FFOUNDATION P. PROPERTY LINE ft sumps ?j WIDTH �+� ft LENGTH fie/' - �ft DEPTH LOQ ft DISTANCE TO NEAREST WELL 45�' R FOUNDATION I V ft PROPERTY LINE Cil�' ft ❑ DISPOSAL PONDS WIDTH ft LENGTH _ -ft DEPTH ---ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ SEEPAGE PITS NLMBER WIDTH ft DEPTH 11 MSTA. .TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY T I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNT] ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. 'Ni 2 -ADVANCE NOTICE REQIIRED FOR INSPECTIONS--PLEASE CALL.(209)953-7697 SIGNED TM,F. Own' DATE j/ X4`07 10 / ' n _ 1 4 7 I 1 1 1 J I S M NI L D ARTME U,�S}E�O Q 1' Vit-P1 {DEP Applimlion Accep Date t I ''t/ Area ,- Employee ID# '-77�/ �( Final Inspection _ Date E3SPECIAL PERMIT-Approved by Character of Soil to Depth of3 t: i / Pit/Sump Soil Character: , COMMENTS �/�rr� � iz i�Y�G'S .�P/��r-r-sir-c c�cam`_ l�� • r PE SC Received Che M/ Amount Date Permit/ Invoice# Permit ID# Code INFO B s Remitted u u• t� S 4