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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 4341-7 W- CFlLI FOr21J I A q u f= CITY/ZlP I RAS-y y G H CROSS STREET44 ��tt APN a(`�-�o ��" PARCEL SIZE "'z' U d I'C OWNER NAME l�r/T E-L- MAF'2.I /A/t-Z / '7- G A PHONE ��/Q/�/-�`�'3 OWNER ADDRESS 4/-70 1�4I-PA C•1 1�- CITYISTATEIZIP RA G T `A 9,6-3-769 y CONTRACTOR CAL S ATE E N G)�JEE21.X/G PHONE -2 0l^�-pV 4/I I� Q rW� CONTRACTOR ADDRESS - g��11oL-7 ZkQADW�� LCITYISTATEIZIP �1+n�50� CA 7S&V-- LICENSE 11 -C-42 OI IC-36 OTHER P` NUMBER 7�,-7C/W3�e EXPIRATION DATE 3-3/- 2-� WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # ( BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: D NEW INSTALLATION REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE n 11 REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM U DESTRUCTION D INSTALLATION WILL SERVE: RESIDENCE O COMMERCIAL L OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS �j ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION it PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it 11 j ❑ FILTER BED WIDTH it LENGTH ft DEPTH it DISTANCE TO NEAREST WELL it FOUNDATION It PROPERTY LINE R ❑ MOUNDED WIDTH it LENGTH it DEPTH it �I DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTYLINE `I Elft SUMPS WIDTH ft LENGTH ft DEPTH t DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it !1 ❑ DISPOSAL PONDS WIDTH it LENGTH it DEPTH it 1' DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH it DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION it 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. !N/ U 8140yaVAQVAN&NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED 1-4— TITLE EKGIPEER DATE �1'SCI G L --7ArE X1 6 r A1(; AZ/Aj11 QA Cr PAIr la�'w l 1� Cc wu�N 4)''P4r1' NT Application Accepted L D E P A R T M E N USE ONLY Date Q Area Employee ID#=� Final Inspection By Date tiO[ SPECIAL PERMIT-Approved by Character of Soil to pth of 3 Ft: Pit/ ump Soil Character: COMMENTS SQ_T sy/ m 46 be v.t;46— IJtj eegj t)47 IF PE SC Received Check#/ Amount pate Permit/ Invoice# Permit ID# Code INFO Cas Remitted Service Request# 01) S2314164- F- 42-01 a3 42-0, ONSITE WASTEWATER TRTMNT SYSTEM PERMIT