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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)168-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ly JOB ADDRESSCITY2IP CROSS STREET /y l APIN 06 S 76 n^I PARCEL SIZE 5— G W I OWNER NAME [� f I PHONE .. OWNERADORESS a t� ` `C1 � U0 CITY/STATEIZIP I CA CA CONTRACTOR � Z : �/�i� 'A0YY \ PHONE, 3d¢-e;�'te CONTRACTOR ADDRESS CITYISTATFJZIP LICENSE '�C-42 YC-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION#_ I TYPE OF WORK: .. NEW INSTALLATION REPAIRIAoornoN ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION I+ INSTALLATION WILL SERVE: 7 RESIDENCE E COMMERCIAL OTHER I NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: �L NUMBER OF EMPLOYEES: SEPTIC TANK _TYPEIMFG Cr fL CAPACITY j�OV gal #01COMPARTMENTS GREASE TRAP TYPE'MFG_ CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL_._-4D2_ it FOUNDATION__"`7 tt PP.OPERTY LIriE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES .. LEACHING CHAMBERS #OF LINES ,Z LENGTH OF LINES q(-) J, DISTANCE TO NEAREST WELL L _ft FOUNDATION U R PROPERTY LINE J It ❑ FILTER BED WIDTH ft LENGTH It DEPTH R DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTYLINE R ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL it FOUNDATION it 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 ft DEPTH ft DISTANCE To NEAREST WELL it FOU NOAT I0 ft PROPERTY LINE ft Q"EEPAGE PITS NUMBER �•- WIDTH 3 (301 k DEPTH 2S It DISTANCE TO NEAREST WELL-/_4��ft FOUNDATION I(7 -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. MI IMUM 24 VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)943-76p7 SIGNED TITLE DATE I --- _ 1 1 it 12 -- 7 <V' O a 106 5 16mx4 �4 If, 9rcfo T" ", c.I AAAA _ -t-j�'., i T-- - - - iL - �- -- -��! � r to • rna bit !u`• �,cS!.yl �/i' H- 1 8-4 —•—=1-.= j I I I I I I i I i _I I I_ I I I DEPARTMENT SE ONLY Applicationtion Date_ Area Employee Final Inspection Date � U SPECIAL PERMIT•Appl{�ved by Character of Soil to epth of 3 t- PIUSum Soil Character: COMMENTS eW 2 Y t r�LrJ 4E-eA&z z r, 3In z _-- PE SC Received .Cbeck* '-,r- Amount Permit/ Date Invoice# Permit ID# Code INFO B Cash I Remitted Service Re uest# 73 1 as-ol i ONSITE WASTEWATER TRTMNT SYSTE&I PER/ 82&09