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A ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 _NON-REFUNDABLE PERMIT 'CLAL`LJ2O�91J 953-7697 FOR INSPECTIONS EXPIRES_I YEAR FROM DATE ISSUED JOB ADDRESS Kos be 5. ST. F'1 p.� RW`� y� //yy g_CITY/ZIP LWT'-iLiF'O R�_ �r?Z37 CROSS STREET P'.bC-Lt- APN JO I 1 0 -L*7-- PARCEL SIZE C 7 OWNERNAME KIST Fi ^' PHONE 201-7 OWNER ADDRESS _, __ CITYISTATEIZIP cL G� CONTRACTORate' �,�-�T•'L w . ` PHONE_CONTRACTOR -57 CONTRACTOR ''^ CONTRACTOR ADORES$ W I S• t+�it.An l•k )k4e' 103" CITYISTATEIZIP LA w"►`Q.I.�C �SZ�kO LICENSE C-42 11.1C-26 OTHER ___ NUMBER - �w EXPIRATIONDATE 07-1-Z-61 L3 WATER TABLE DEPTH: __fl GEOGRAPHICAL INFORMATION: Coordinates X Y - r.l PERC TEST # BUILDING PERMIT# D 7 O _LAND USE APPLICATION# TYPE OF WORK: III NEW INSTALLATION I I REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE j REPLACEMENT U OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: id RESIDENCE - 1 COMMERCIAI U OTHER NUNBER OF LNtNG UNITS: I NUMBER OF BEDROOMS: NUMBER of EMPLOYEES: SEPTICTANK TYPERAFG PftC $T L CAPACITY f4Ltl�• gal #OFCOMPARTMENTS_ Z -. ❑ GREASE TRAP TYPFIMFG CAPACITY c gal it OF COMPARTMENTS DISTANCE TO NEAREST: WELL 100 „._ It FOUNDATIO14 7r ft PROPERTY L,NE 'e"M ft ❑ LIFT STATION SIZE TYPE OF PUMP U PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES A LEACHING CHAMBERS #OF LINES LENGTH OF LINES_ DISTANCE TO NEAREST WELL I oOr R FOJNDATION S� h PROPERTY LINE Z-oO It ❑ FILTER BED WIDTH 11 LENGTH _.__tt DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION $ PROPERTY t INE R ❑ MOUNDED WIDTH it LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH R DISTANCE TO NEAREST WELL ,it FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEP-H ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PRCPERTY LINE E i� SEEPAGE PITS NUMBER Z WIDTH• 3(w tr ft DEPTH - it DISTANCE TO NEAREST WELL I pC7 t IT FOUNDATION 1 CO r ft PROPERTY LINE Z.00 it 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 REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 f SIGNED TITLE DATE 1 S+4r„C43 PWK-- i - ^EN- - to+3 -� - -- - lot A it / T'! I I I 1 -- � DEPARTM NTLI E DAILY r Application Accepted-By --�� Date Area t . Employee IDp- Final Inspection By/ l Date :_ J SPECIAL PERMIT-Approved by Character Of Soil to Depth of 3 Ft: PIU8ump Soil Character: COMMENTS i - _ � PE SC `Received _ Check#!. Amount Date Pennitl Invoice# - Permit ID# Code INFO —Gish Remitted Service Re uest# • I 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT W1110