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v ONSITE WASTEWATF,R TREATMENT SYSTEM PERMIT /SAN JOAQUIN COL'NTy ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3°"FL•STOCKTON CA 95202 - (209)468-3420 NON-REFU NDAijjEjftRMly CALL(209)951-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS - /F.►��.�••�j�� 11�'F�� 1r CITY'/ZIP H CROSS S)REET APN__ PAR(:EL SIZE Y OWNEx NAME pQi-ft'� OWNER ADDRESS / l l t^ ' CITYISTATE/Zl� {t�TjJ �/r ryry CONTRACTOR - PliONE CONTRACTOR ADbRFiS`T // J 1� /�W � AY f C IITT%1StTATFJZIP ' ' (f LICENSE -42 ❑C-36 OTHER /'� NUMBER (W✓1 EXPIRA))OV DATE 1 O WATER TABLE DEPTH:_ R GEOGRAPHICAL INFORMATION: Coordinates X Y Y ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# TYPE OF%WORK: AO� L3 NEW INSTALLATION ❑ pA1RIADDITI V L) ENGIAEER DESIGNED/ALTERNATIVE /< REPLACEMENT _ A�I{��u�1 , 1.r CTION INSTALLATION'WILL SERVE: LJDE RESINCF ' COMMERCIAL ❑ OTHER— tiUMBEROFLIVIVC UNITS: NUMBLR OF BEDROOAI.C: NUMBEROi;EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal M1 OF COMPARTMENTS _ ❑ GREASE TRAP TYPEMcGCAPACITY_______ gal k OF COMPARTMENTS 4 O PKG TX PLANT DISTANCE 7'ONEARE:3T: WELL ft FOUNDATION f, PROPERTY LINE ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS k OF LINT.$ _ LENGTH OF LINES DISTANCE TO NEAREST WELL it FOUNDATION_, R PROPERTY LINE _ ft ❑ FILTER BED WIDTH _^ft LENGTH ft DEPTH___ R DISTANCE TO NEARFST WELL_ _ft FOUNDATION- R PROPERTY LINT R ❑ MOUNDED WIDTII R LENGTH _R DEPTH ft DISTANCE TO NEAREST WELL ___R FOUNDATION ft PROPERTY _ ft ❑ SUMPS WIDmi ft LENGTH R DEPTH DISTANCETONEARF.ST WELL R FOUNDATION __ ft PROPERTY _ _R ❑ DISPOSAL.PONDS Wtunt $ LENGTH_ R^ DEPTH _ It DISTANCE TO NEAREST WELL V R FOUNDATION R PROPERTY L:a_ it ❑ SEEPAGE PITS WIDTH_ ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELT. `ft FOUNDATION ft PRGPERI Y LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANDTHE WOR).WILL BE DONE.IN ACCORDANCE WITH SAN JOAQUIN COUNTYORDINANCES, 4/rr�q{�111��)''''��'(^/{ ` '+1�'1\ ((('''�� STATE LAWS AND RULES AND REG('LATIONS OF SAN JOAQUIN COUNTY. $IGNF:�1/ IJP�,JNIML'NL.T 'AC NOTICE REQUIRED FOR V. 101 5-P EAST.CALL 120V19t3-7691-7 q L�JI TFTL J�L_Mt LY -_ _ DATE //V Q� (,Q k 3 i 3 1 r O - 3(C EAL H S RVI ES DFPARTM T UtiE ONLY /� Apptication Accepted By - Date -ily� Atr� �r-1 - Employee l D#_L .___{O Final Inapectloo By_ ___ Date G 9 Q SPECIAL PERMIT-Approved by _ Character of Soil to th of 3 Fr- Pit/Sump Soil Character:// COMMENTS CL ZSt� u 91� a 4 PE SC Recelved Check#/ Amount Date Invoice# Permit ID# Codc Inco 8 Cash Remitted Service Re nest#