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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 T q�y r pCALL (209 953-7697 FOR INSPECTIONS p EXPIRES t1/YEAR FROM DATE ISSUED JOB ADDRESS 2-01�V'r �• 1S��v I��' CITY/ZIP T f^\C�y 1 ` Z, =a 02-0 CROSS STREET .�,y^-7�� APN Z �jQ,�J�/ PARCEL$RE p OWNER NAME C"^�NX'T �f3-VTL--A / iyIMOPHONE j-32, - 50019 M OWNER ADDRESS 39 T-0 N 1 �,`, `v� `� CIN/$TATE/ZIPJ qT PZfy(-kj CA -`�/0 4 CONTRACTOR L-I\fe O1PC� (rEpElV�/1�CN►'►'�E PHONE 36 /- 031 , CONTRACTOR ADDRESS 1 44-). C)^Y— �� CITY/STATE/ZIP L-001 C V LICENSE _C-42 C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST #_--3_ BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: - NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT I.i DESTRUCTION INSTALLATION WILL SERVE: 7 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 It FOUNDATION ft PROPERTY LINE It ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES C LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ FILTER BED WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE 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 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE JfV(-'FN--r DATE I VICINITY MAP O o IT z it i �Q _ i ... €; tI L" 01 jN �N /Rp Cp(/ EPARTMENT SN�, I Application Accepted Date �j �j(/y Area Employee ID# Final Inspection By _ Date SPE IAL PERMIT-Approved by Character of Soil t Depth of 3 F Pi Sump Soil Ch cter: C MENTS L r t a PESC Received heck#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B Remitte Service Request r 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT