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/00 j ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-ST40CKTON CA 95202-(209)468-3420 NON-REFUNDABLE PERMIT �. CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 7 Jos ADDRESS f&A e, Q` ®' f .P`•'`^y��a CITY/+Z�IP� C) v CROSS STREET APN �—�GC/ DE � PARCEL SIT OWNER NAME 1VI' A—t N TF 1)�/`l t� PHONE 7-`i-3�-1�1c) ra I OWNER ADDRESS .I CITY/STATE/ZIP CONTRACTOR ��OR"� S ►L Dlr I' kl4 -+'•"Lr PHONE C.Yr 1—�•2�� A Q ry cr,� j CONTRACTOR ADDRESS 2�1 S- �.vL;LD PC'V E• tO3 CITY/STA7E/ZIP L06�i, CA iS C.��'V K� �pp LICENSE RLC�2 �_C-36 OTHER NUMBER 6� EXPIRATION DATE �� I 1 WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y 1 ❑ PERC TEST # BUILDING PERMIT# 9T LAND USE APPLICATION# TYPE OF WORK; NEW INSTALLATION REPAIR/ADDITION O ENGINEER DESIGNED]ALTERNATIVE L REPLACEMENT C DESTRUCTION INSTALLATION WILL SERVE: Y RESIDENCE COMMERCIAL ^� C OTHER NUM6ER OF LIVING UNITS; ( NUMBER OF BEDROOMS: i_.yn� NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG^WCZ10L CAPACITY�'( 0 gal #OF COMPARTMEM'S�_ . ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS —i-— DISTANCE TO NEAREST; WELL 1001+ ft FOUNDATION S ft PROPERTY LINE *f ISI n f 0 LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES IV LEACHING CHAMBERS `#OF LINES �_ LENGTH OF LINES LAD� ft , DISTANCE TO NEAREST WELL teD C>I+ It FOUNDATION lot ft PROPERTY LINE t ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELi It FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft O DISPOSALPONDS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WEL: ft FOUNDATION It PROPERTY LINE ft SEEPAGE PITS NUMBER 7 WIDTH .71L+T� ft DEPTH e-77I R DISTANCE TO NEAREST WELL I Sty f ft FOUNDATION SQr It PROPERTY LINE L O 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. INIM 4 IJOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED ! TITLE CCS L DATE D412.3j" i ni 0 _..v __.� __=w DE TMENTiI E Y-� -..— +--^�HFJ�LTH DEPARTMENL.._. Application Accepted f _�Date j _ Area Employee ID# Final Inspection By Date SPECIAL PERMIT-Approved by Character of Sol]to Depth o Ft: PitlSump Soil Character: COMMENTS A�)L Q.L1''W �7 .rr�'r��irG C� X F7 yp' 2_-. 1.4Le-16—s rn PE SC Received heck#/ Amount Date P Inv Ice# Permit ID# Code INFO Remitted ervice R ueb 42-0i ONSITE WASTEWATER TRTMNT SYSTEM PERMIT tOW07