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/ (90ONSITE WASTEWATER TREA rMENT SYSTEM PERMIT - SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3Y°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS 17�5CITY/ZIP g5a377 CROSS STREET 7T-1 � h-S APNO i q '7 7 PARCEL SIZE p5Q,3O OWNER NAME _r d 'e !D�Q�2}PHONE � OWNER ADDRESS ��O uCITY/STA'1'E/ZIP�" SP r i jrd:m 64 CONTRACTOR J of ��...ffL.. ` PHONE1 CONTRACTOR ADDRESS C CITY/STATE/ZIP ^_J LICENSE ❑C-42 O C-36 OTHER NUMBER EXPIRATION DATE v) WATER TABLE DEPTH: ft GEOGRAPHICAL INPORMATION: Coordinates X Y ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# _ m TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE 1 1 1 ❑ REPLACEMENT CI DESTRUCTION INSTALLATION WILL SERY'E: RESIDENce ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: q NUMBER OF EMPLOYEES: - �^�r} a SEPTIC TANK TYPE/MFGnCt'QV' CAPACITY gal gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS n ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION R PROPERTY LINE A ❑ LIFT STATION SIZE TYPE OF PUMP O SAND OIL SEPARATOR(ENCLOSED SYSTEM) c-+ LEACH LINES ❑ LEACHING CHAMBERS -T,,, #OF LINES LENGTH OF LINES DISTANCE TO NEAREST WELL '-V 0 ft FOUNDATION 7 1 b ft PROPERTY LINE 7 O R ❑ FILTER RED WIDTH R LENGTH ft DEPTH It DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE fl Q ❑ MOUNDED WIDTH R LENGTH ft DEPTH ft DISTAMCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R O SUMPS WIDTH ft LENGTH ft DEPTH R DISTANCETO NEAREST WELL R FOUNDATION ft PROPERTY LINE R ❑ DISPOSAL PONDS WIDTH n LENGTH ft DEPTH ft DISTANCE TO NEARESTWELL n FOUNDATION n PROPERTY LINE ft it SEEPAGE PITS WIDTH %? n LENGTH it DEPTH •2S ft DISTANCE TO NEAREST WELL > -T-OC R FOUNDATION ? 10 fl PROPERTY LINE r ft I HEREBY CERTIFY THAI'1 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. MINIMUM 24 H'OJURI ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED oJ�-' 'V� TITLE �1I J 11n t IL DATE (0"1;k3---03 0 10 Pat 00 00 :0 r7l.1111111 J a NV1 ^ DEPARTMENT USE�O�NsL-�Y� Application Accepted! [IEmployee ID# By Date Final Inspection Date J�D'S SPECIAL PERMIT-Approved by Character of Soil to hof 3 t: Pit/Sump Soil Character: COMMENTS PESC Received Chec Amount to Permit/ Invoice# PermitID# Code INPD B ash Remitted Service Request# 1Ii In !02 3z c b a�