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ONSITE WASTESTER TREATMENT SYSTEM a+ERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR7NKT 304E WEBER AVE -3``-STOCKTON CA (209 6 - NON -REFUNDABLE PERMIT CALL209!� 9.5„.3-ee7697 FOR INSPECTIONS EXPIRES I YEAR FROM I, I C _l 1.��_ n C.�O.-. N W • -VrQ.Caa( CITY/ZIP q <-.3 7 tP JOB ADDRESS " CROSS STREET AL� CL -e) • APN —04 PARCEL SIZE OWNER NAME CiTYISTA SCL TE/ZIP I ' a-� / OWNER ADDRESS ^ — IL P PHONE rajA� CITY/STATE/ZIP CONTRACTOR ADDRESS LICENSE ❑ C-42 ❑ C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # t _-. n n........u.....r...N ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCI L ❑ OTHER_ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF ❑ SEPTIC TANK ❑ GREASETRAP ❑ PKG TX PLANT ❑ LIFT STATION TYPE/MFG CAPACITY gal # OF COMPARTMENTS TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL tl FOUNDATION Il PROPERTY LINE ft SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS ft # OF LINES LENGTH OF LINES DISTANCETO NEAREST WELL DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH WELL ❑ B DEPTH NUMBER WIDT DISTANCE 10 NEAREST WELL Il FOUNDATION Il PROPERTY LINE ❑ MOUNDED WIDTH tl LENGTH it DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft Dale ft PROPERTY LINE DISTANCETO NEAREST WELL ❑ DISPOSAL PONDS WIDTH ft P-0G`t30ic ft DISTANCE TO NEAREST WELL ❑ SEEPAGE PITS NUMBER WIDT DISTANCETO NEAREST WELL I HEREBY CERTIFY THAT 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTI,O,NS� PLEA/S,E CALL (209) 953-7697 SIGNED TV./fiA�o. l'�i^" JUGA TITLE !Lk I^^ DATE —I Application Accepted Final inspection By j Character of Soil to C COMMENTS ) - ol/- 4[s DEPARTMENT USF ONLY Date e*�Z 3 1 uS— _ Date Pit/Sump Sob T�p �1 rh J Area Employee IDN ❑ SPECIAL PERMIT - Approved by PE Code ft DEPTH R FOUNDATION Dale ft PROPERTY LINE Permit ID# ft DEPTH ft FOUNDATION it PROPERTY LINE P-0G`t30ic ft DEPTH n FOUNDATION n PROPERTY LINE I HEREBY CERTIFY THAT 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTI,O,NS� PLEA/S,E CALL (209) 953-7697 SIGNED TV./fiA�o. l'�i^" JUGA TITLE !Lk I^^ DATE —I Application Accepted Final inspection By j Character of Soil to C COMMENTS ) - ol/- 4[s DEPARTMENT USF ONLY Date e*�Z 3 1 uS— _ Date Pit/Sump Sob T�p �1 rh J Area Employee IDN ❑ SPECIAL PERMIT - Approved by PE Code SC Received INPO B Check#/ Amount Remitted Dale Permit/ Invoice# Service Request # Permit ID# 42.21 ods p/—-cc3 7 D P-0G`t30ic 4202-001 ONSITE WASTEWATER PERMIT 12/22/2003