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r ONSITE WASTEWATER TREATMENT SYSTEM PERMIT I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT Jt" CA L(209)95 76 7 FOR INSPECTIONS 'EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS We7c CITY/ZIPJb 1! m CROSS STREET I _APN 15-0,,28- PA/RCEGL SIZE 53 > 1 OWNER NAME ! NO SPiMAr ee '/�PHO'NEg?q O4 d37c`-711/f 4 ' `'/ p OWNER ADDRESS ��T�,('lO //��'(I`'k" G� -C - CrIV/STATF/ZIP CONTRACTOR - PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP I LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# D LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE Cl' I REPLACEMENT 1 ❑ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE, ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG TNF CAPACrrY / OO gal #OFCOMPARTMENTS Z ❑ GREASE TRAP TYPE/MFG I. CAPAC - gal #OF COMPARTMENTS ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft 'PROPERTY LME ft ❑ LIFT STATION SIZE `TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENc ) w LEACH LINES Ll LEACHING CHAMBERS #OF ES � LENGTH OF LINES ft GN DISTANCE TO NEAREST WELL ft FOUNDATI N. R PROPERTY LI E ft 0 I` ❑ FILTER BED WIDTH Fl LENGTH ft DEPTH ft `Q, I DISTANCE To NEAREST WELL - R FOUNDATION ft PROPERTY LINE ft 1 ❑ MOUNDED WIDTH ft LENGTH R DEPTH ft R rDISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft l ❑ SUMPS WIDTH ft LENGTH ft DEPTH - ft DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH" ft DEPTH ft DISTANCE TO NEAREST WELL -ft FOUNDATION R PROPERTY LME ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft (� DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE $ 1l> l 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. MINIMUM 24 HOUR ADV NCE NOTI RE�UI ED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED ��/J/I O .LI�_��lf�/L(� TITLE Q7 GJ A)6-10- DATE NEW -SEPTIC SYSTEM I I PREC v D I 139' +/- Ju*1 SIDEN E 1` 1 0 NEW WELL, pU1N GpU� �Ipao-0;nust I gptENv apNMEK�M I,B• I �THpEPAR ,.1.1 (o I H + - mo A 156' +/- F P-T-. { I i( ) i1l H - - L DEPARTFiE: Application Accepted By te, (0 Area Employee ID# 40 4-- 9 Final Inspection By ate jq ice'. ❑ SPECIAL PERMIT-Approved by / Character of Soil to Dep of 3 Ft, Pi U ump Soil Character: COM NT PE SC Received Check# Amount Date Permit/ Invoice# Permit lD# Code INu FO B " h- _ Remitted Service Request# L{ZN a 1007 o W 5I