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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 *NON-REFUNDABLE PERMIT n1 CALL 209)953-7697 FOR INSPECTIONS EXPPIIREES1 YEAR FROM DATE ISSUED JOB ADDRESS (03 CP 2. CA PIM.-/tJy C--r-- G CIN r—T/ZIP S-raC- V -j 99"24y- CROSS 9"245CROSS STREET LOQ��F�y APN C a O 43� PARCEL SIZE �� AC - o OWNER NAME F�^,v �yIN r V 1—O PHONE 405-- OWNER ADDRESS S A M G CITYISTATE/ZIPP p CONTRACTOR LIJE [[D��- GE0V`JyIZoNV"&J-TA — PHONE 3� 7 03'7T' o f CONTRACTOR ADDRESS 40 1 w' 0• ''— s�� CITY/STATE/ZIP I^��I GPS –!�2,4 LICENSE i�C-42 L C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT I DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It A Y DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft L3 MOUNDED �CA'�MOUNDED WIDTH ft LENGTH DEPTH ft V DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft �® ❑ SUMPS WIDTH ft LENGTH It DEPTH ft G 4 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE SAAB✓ ?019 13 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH cF q / DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE �lfr. O/yM CpU� ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft �FpgRT7.14 DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft MFH) I 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. INIMUM 2�R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 G �f a SIGNED, /`� L TITLE GONSVLI ANT DATE 6 - 1 EPARTMEN E Application Accepted Date l( I Area Employee ID# Final Inspection By Date SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received he Amount Date Permit/ Invoice# Permit ID# Code INFO Bv ash Remitted Service Re uest# ?� l> f �qvjlfli 42-Ot ONSITE WASTEWATER TRTMNT SYSTEM PERMIT