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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)488-3420 NON-REFUNDABLE PERMIT CALL209 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS _ U T✓�V �`-L _ CTTY/ZIP CROSS STREET Itl��{✓-Ia A41 --- APN 013 'So 4 _P/A,RC�E,LL StZE_ OWNERNAME '`tl��f �- ems' C _..__ -PHONE -)'17V q7�`� OWNER ADDRESS a 3 J 1 04 is t7� CITY/STATE/ZIP 4/ q Ste`1tv __ y CONTRACTOR M e 7G ______ _PHONE 133 -13 ! (',7 CONTRACTOR ADDRESS O Is- s fe.t "" h C...(_�._ CTTY/STATE21P a a/ ��T LICENSE LIfIC-42 11JC-36 OTHER NUMBER!YPS1 EXPIRATION DATE_.--_ WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATK)N: Coordinates X Y ❑ PERC TEST M BUILDING PERMIT#►___ _ _ LAND USE APPLICATION TYPE OF WORK: NEW INSTALLATIoN 1 i REPAIR/ADDITION LiENGINEERDESIGNEWALTERNATIlVd- REPLACEMENT 11 OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE lJ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNfr3: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY _ gal MOF COMPARTMENTS_ ❑ GREASE TRAP TYPE/MFG - CAPACITY _ gal If OF COMPARTMENTS_—_ DISTANCE To NEAREST: WELL _._ It FOUNDATION It PROPERTY LINE ft ❑ LIFT STATION SIZE _ _ TYPE OF PUMP____ - ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS MOF LINES____ LENGTH OF LINES It DISTANCE TO NEAREST WELL _._ it FOUNDATION R PROPERTY LINE it ❑ FILTER BED WIDTH __ ____it LENGTH_._ --ft DEPTH _ ft DISTANCE To NEAREST WELL __- it FOUNDATION It PROPERTY UNE it ❑ MOUNDED WIDTH It LENGTH It DEPTH It DISTANCE To NEAREST WELL_____ fl FOUNDATION _it PROPERTY UNE ft ❑ SUMPS WIDTH _it LENGTH__- _ It DEPTH it DISTANCE To NEAREST WELL--- ft FOUNDATION--it PROPERTY LINE ft CI DISPOSAL PONDS WIDTH_ _ it LENGTH ft DEPTH R DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY UNE it ❑ SEEPAGE PITS NUMBER WIDTH _ it DEPTH R DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE R I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WTTH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIM 4 OUR AD AN E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 9 697 SIGNED_ TIT _ D v At OA o ❑ 1 UwT D E A R Data L kZr� Application AccjDe Date_. 1 Area Employee IDU rs c-J Final Inspection Date_ ❑ SPECIAL PERMIT-Approved by Character of Soif 3 Ft: _ Pf ump Sol,Character:COMMENTSD -n l` ' PE SC Received k Amount Date Permit/ Invoice M Permit IDM Code INFO B cash Remitte Service Reguest M 22� 0� 7 bg�2 lO tot t`I 52 �-O-+ '1 $ 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 417412