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ONSITE WASTF'ATER TREATMENT SYSTEP - PERMIT SAN JOAQUIN COUNTY ENVIRONMEN'T'AL IIKALTH DEP ENT 300E WEBER AVF.-atteFL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR IN'SPEC'TIONS EXPIRES I YEAR FROM DATE ISSUED 'Tr- W, X15'377 JOB ADDNl:.RS CI'I'Y!'LIP n 11 1' C(�� /'' /� 9 CROSS STREF:r 1"i0.1Y wN Iy1G T 1 I APN ?ffl-W -zs PARCEL SIZE `Ib.14 OWNER NAME N�;411 C-e 1 c*,C� `L``C OWNER ADDRESS C�/�b] ` CITYBTATE/LIP 1 3Z0 2- CONTRACTOR CONTRACTOR e PHONE 2nCj-Q4j6-j7,LM CONTRACTOR ADDRESS 2Z2-S- F CT'ISTATFJ21P A 55-w5-- LICENSE ❑C-42 E3 C-36 OTHER NUMBERLy- al2,—L_g_ EXPIRATIONDATE I�L-31-may WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST(S) NUMBER 1_ LAND USE APPLICATION N PA-04-1-S-7 TYPEOFWORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBEROF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTICTANK TYPEIMFG CAPACITY gal NOF COMPARTMENTS ❑ GREASETRAP TYPEIMFG CAPACITY gal N OF COMPARTMENTS ❑ PKG TX PLANT DISTANCETO NEAREST: WELL R FOUNDATION R PROPERTY LINE Il C' ❑ LII•TSTATION SIZE TvPE OF PUMP O SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACIIING CIIAMBERS N OF LINES LENOTH OF LINES Il �- DISTANCE TO NEAREST WELL Il FOUNDATION ft PROPERTY LINE Il 1 ❑ FILTER BED WIDTH R LENGTH ft DEPTH R DISTANCE TO NEAREST WELL Il FOUNDATION R PROPERTY LINE A (3 MOUNDED WIDTH R LENGTH R DEPTH Il DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH R LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL fl FOUNDATION R PROPERTY LINE it ❑ DISPOSAL PONDS WIDTn ft LENGTH R DEPTH R DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R ❑ SEEPAGE PITS WIDTH ft LENGTH It DEPTH R DISTANCETO NEAREST WELL Il FOUNDATION R PROPERTYLINE R 1 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. NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE S+wfc Er\dnetr DATE.�b/{ w E smmert mr.rr C 1 _ Ap1M 1 i y. '10°UaTrI iT' 1919 1[WM I I( c � Ska•"'^'� �� P �� g' I � P 1 , F ; �1 YR• �s' F._a 4 I LT DEPARTMENT USE NLV U; LJQ Application Accepted By Date -J ; �) Am �,IL tmployec ID# III Find inspection By " • t ^� - Dale 1 t ❑ SPECIAL PERMIT-Approved by Character of Soil to De oT3 FI: PIUSum Soil Character E- ��- ----------- - COMMENTS A` It!Al PE SC Received eeRN Amount Date Permit/ Invoice# Permit ID# Code INFO B ash Remitted Service Request a z.a 5z! (3 3 oc7 uJ ap f��/3� 42-01-091 ,f 1't dA 122/02 I1 Tr�1 0 � �_ i ONSITE WASTEWATER PERMIT i.'.