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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 96202-(209)468-3420 NON-REFUNDABLE PERMIT �7 CALL 2.0J)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1 /S 5-52 + ST S• C PVN, �" Y � CITYIZIP CROSS STREET OAl�K t&�CrDQ APN '5-5 - 140 `3J PARCELSRE 2•'L5' b 'j-7 ( 0 OWNER NAME A``E PJ �1 N PHONE �7 OZ,3 �(`9Z-y 2 y OWNER ADDRESS -7 '/ C, �' "•,1F- (CT-0 IPA> • CITY/STATE/ZIP CONTRACTOR G Oh1L^� .w tr 0 EN V 1(zOn/M CAJT A L PHONE ��J3 `I-0 3 • CONTRACTOR ADDRESS T� r b �Aw- S'r- CITYISTATE/ZIP � I CA 415-Z-440(SL4 O LICENSE C-42 C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y )C PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT DESTRUCTION INSTALLATION WILL SERVE: I RESIDENCE COMMERCIAL i 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 It ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES 1:, LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL 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 It ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It DISTANCE To NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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. MINIMUM�2 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)963-7697 SIGNED TITLE -OKf•rLT�'1'/d"� DATE 1,1? /At 77'1- OF A4 �Y FNT • DEPARTME T,!ISE QALY Application Accepted By Date / Area loyee ID# c Final Inspection By Date ii L I SP9gIAL PERMIT-Approved by Character of Soil to Def tMof 3 Ft: Pit/Sump Soil Character: COMMENTS �,tii yA > PESC Received .Chec Amount ate Permit/ Invoice# Permit ID# Code INFO B /7 Remitted Service Re uest# V s 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT