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ONSITE VVA .WATER TREATMENT SYSi'M PERMIT ! SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E IviAIN STREET-STOCKTON CA 95202-(209)468-3420 NON-REFUNDABLE PERMIT � CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS IC] 1 C �� t ITA,�j S'L&'r P-PP CITYIZIP Lo-0 ,^wj c E �^ X7 p � � CROSS STREET T 4Tr l- P,.L�" 1 Al 5 PARCEL SIZE d o I OWNER NAME cJYty _ _ PHONE OWNER ADDRESS P© XS CITY/STATE/ZIP 4 CONTRACTOR '+� C_ Z L{-i"L.G+ ZWC PHONE - fCSG'l'Z-5S fZ E CONTRACTOR ADDRESS C l • �1LA .-� I��y• �Q _ CITY/STATEIZIP �L� �1�r z,>40 LICENSE hi C42 ❑ C-36 OTHER NUMBER 15q'5416 EXPIRATION DATE b � WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# 0(23 LAND USE APPLICATION# I _ � TYPE OF WORK: NEW INSTALLATION O REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: 19 RESIDENCE © COMMERCIAL P- ❑ OTHER NUMBER OF LIVING UNITS: Win. 1 NUMBER OF BEDROOMS: fa NUMBER OF EMPLOYEES: lb _ SEPTIC TANK TYPE/MFGCAPACITY Rv© gal #OF COMPARTMENTS ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS t � DISTANCE TO NEAREST: WELL VSO f`t- ft FOUNDATION S F ft PROPERTY LINE R ^ ; !1 I ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ .LEACH LINES Id LEACHING CHAMBERS #OF LINES __ LENGTH OF LINES ft C DISTANCE TO NEAREST WELL I S-01`w' ft FOUNDATION SSI ft PROPERTY LINE L� t ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft V` I I3 MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft j SEEPAGE PITS NUMBER A _�WIDTIi z I f ft DEPTH Z J t ft DISTANCE TO NEAREST WELL - +0 ft FOUNDATION too f ft PROPERTY LINE kpo ft I HEREBY CERTIFY THAT I 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 REQUI R I SPEC�nTII,O,,N�JS-PLEASE CALL(209)953-7697 SIGNED _ l f��+j DATE t00310-7 4y IRE-1 IL 4 � I I I I N EPARTMEN'T-US ' Application Accepted Date © Area- Employee ID# 5 tplG -�Gj Final Inspection y Date '❑ SPECIAL Ri1'IIT-Approved by ; Character of Soil to epth of 3 F� Pit/Sump Soil Character: COMMENTSt.07 4 F 4=,z,.�4 /I.�c a PE SC Received Amount Date Permit/ P mit D Code INFO B ash Remitted Service Request# Lf S 42-01 ONSITE WASTEWATER PERMIT ncnnronn-+