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V14J1 I" vvrL 1 IZVVr 1 CE[ I RCN 11#1CIV I J T O I CIYI rr-KIVII I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 NON-REFUNDABLE PERMIT CALL 269 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JDBADDRUa 7-5"09-1- Lstmm ERS RD, �p CwruP -Txioi - '` In Cams STREET SSG fl V LTE APN 2-0 !- 2-S-0- 41 c�PARCELS'QyE T ��J•�/ y OMERNAME A5t>vL r-RASNMAPQAL.h PPHONE Sio-(vIP-4&44 • OWNERADDRESS k4-:'r VJAI Lftf• CRYASTATE/ZJP FAC4 C-A 9S-30q- CONTRACTOR LIVE o r<Y &e0EQ V j iZ0/LJm E7%.rTA L 9 PHONE 3 to -0:1 i COHNa CtOR ADDREss `'f0-+ W• OAU.- ST'• CDY1STATE/ZIP "D I CA 9SZ-4O LICENSE QC-42 QC$6 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y x PERCTEST #--L— I BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAWADDITION ❑ ENGINEERDESIGNEDIALTERNAME ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILLSERVE: ❑ RESIDENCE 11 COMMERCIAL 11 OTHER NUMBER OF WING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACrTY gal #OFCOMPARTMaN7a ❑ GREASETRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft ❑ LIFTSTATION SIZE TYPE OF PUMP O PKGTXPLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS #oFLINEs LENGTHOFUNES ft DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH it DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH It LENGTH ft DEPTH it DISTANCE To NEAREST WELL R FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH It LENGTH ft DEPTH it DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE - ft ❑ DISPOSAL PONDS MOTH R LENGTH ft DEPTH R DIsTANCETo NEAREST WELL - ft FOUNDATION A PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE To NEAREST WELL ft FOUNDATION It PROPERTYLINE ft • I HERESYCERTIFYTHATI HAVE PREPARED THISAPPOCATION AND THEWORKWIU.BEDONE INACCORDANCEWITH SAN JOAQUIN COUNTYORDWANCEB, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. IM/Ul y�24,pHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2D9)953-7697 SIGNED g! MIN�'/�\ TITLE CLNSVLTA7-r DATE Cf-22`149 I 7 _. ----�-- ----=---- Res------------- AY "hROu FTTT DEPARTMEM SE O LY �� Application Accepted B Date C% Area Employee ID# /�I� ('0 Final Inspection By Data ❑ SPECIAL PERMIT-Appmve0 by Character of Soil to Depth of 3 Ft PR/Sump SoU Character: COMMENTS • PE SC Received Amount Code NFO Data Fermd/ Invoice Permit l0# I8 Cash Remkted Sallee Re ueat# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT