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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1958 E.HA2ELTON AVENUE-STOCKTON CA 3520$-(209)468-d20 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Z5-01 W. PL ftTrI pj> CIrY/ZIP ^7`R11,�wC'4 CK,304 yam, � CROSSSTREET �'�. APN t ^! iD P,1A�R.0 ErL S[TgE•�3(2•�� t. a OWNER NAME MlCt-3-&EL_ &IL VA PHONE !nP4 Oap� N OWNER ADDRESS 2-9- MAN)CySd CTIY/STATFJZIP T -r-`j CA `1 S 3 d4 CONTRACTOR Ltyrf: 0/w--1G'F.4 � ti�^• m�N l�7ti PHONE 3 - O- 1-T CONTRACTOR ADDA FSS _ `T4 f W C7 ACS ST CfTY/STATEM, -0.1 1 ( 'CA S � 1�d LICENSE. 0:-C-42 OCCti36 OTHER-CCC-CCr+C7- NUMBER 4-1 S EXPIRATION DATE "4 `30 WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y RERC TEST / I I r- _qUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: _ NEW INSTALLATION ❑ AEPAIR/ADOITION ❑ ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERV E: it RFStDENCE COMMERCIAL E OTHER NUMBER OF LMNG UNITS: NU M5 ER OF 8EROOM$: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal If OF COMPARTMENTS 13 GREASE TRAP TYPEJMFC. CAPACITY ®at #OF COMPARTMENTS DISTANCE TO NEAREST; WELL ft 'FOUNDATION ft PROPERTY LINE ft 0 LIFT STATION SIZE TYPE OF PUMP 0 PKGTX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) O LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTYLINE ft 13 FILTER BED W[DTH ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL ft FOUNDATION If PROPERTYLINE _ It Q MOUNDED WIDTH ft LENGTH ft DEPTH it DISTANCE YO NEAREST WELL ft FOUNDATION It PROPERTY LINE It O SUMPS WtorH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTYLINE ft C1 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION if PROPER:TYUNE It C] SEEPAGE PITS NUrIeEA WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTYLINE It I HEREBY CERTIFY THAT]HAVE PREPARED THIS APPUCAT10N ANDTHE WORK W]LL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUMR ADVANCE��•• NOTICE RE CARED FOR INSPECTION -PLEASE CALL(2(79)03f!767 SIGNED L TITLE eppOAo rKC7 DATE Cf f Fp j� tip k4lC . 00 �'��- I DEPARTMENT U E C1NLY Application Accepted By Z— Date 4 a (,j Area Employee ID# _ Final Inspection By Date C,. SPECIAL PERMIT-Approved by Character of Sail to Depth of 3 FT: PidSump Sell Character:. COMMENTS PE SC Received hec Amount Permit/ Cade INFO h emitted Die Service R uest# InraiCe a Permit lOi gda Sa fi /k56 k5Io 5 �d3 42.01 ONSITE WASTFwATER 7RTIMSNT SYSTEM PERMIT 4114M8