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h ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"0 FL- SSTOOCKTON CA 95202 - (209) 468-3420 Wnwl D.U.—n. D1 s 1PVDUNY CALL (2091953-7697 FOR INSPECTIONS EXPI'1(1'.S 1 YEAR FROM DATE ISSUED JOB ADDRESS t CITY/ZIP I(ry' CROSS STREET 1 SIZE 4i P ( , 1 J S APNZ-30/I �.Ci {�PARCEEjL - � OWNER NAME 4P. i1 Z q VV- " � tf E� YA C) PHONE l X OWNERADDRESS )I D d/'CITY/STATE/ZIP �y�/ CONTRACTOR r rl o �+' PHONE •� ' 7 G 4^ f� �' `n CONTRACTOR ADDRESS ;J..'t& CITY/STATE/ZIP " LICENSE ❑ C-42 ❑ C-36 OTHER A. NUMBER EXPIRATION DATE I WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERCTEST # BUILDINGPERMIT# LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION LK REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: 01 RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: _ NUMBER OF BEDROOMS: �t. NUMBER OF EMPLOYEES: y P 1 CAPACITY F% F� CJ # OF COMPARTMENTS i ❑ SEPTIC TANK TYPE/MFG JL gal ❑ GREASE TRAP TYPE/MFO// CAPACITY, gal # OF COMPARTMENTS L3 PKC TX PLANT DISTANCE TO NEAREST: WELL 61 C7 ft FOUNDATION :� it 'lo + D ❑ LIFT STATION SIZE TYPEOF PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS' _ d # OF LINES j LENGTH OF LINES DISTANCE TO NEAREST WELL / ✓9 & 't ft FOUNDATION % d it PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 11 ❑ MOUNDED WIDTH B LENGTH H DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft ❑ SUMPS WIDTH R LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL B FOUNDATION it PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH A LENGTH It DEPTH ft DISTANCE TO NEAREST WELL it ft PROPERTY LINE ft L3 SEEPAGE PITS `FOUNDATION �n NUMBER 3 WIDTII d G= "'ft DEPTH .0�E' 7 r It DISTANCE TO NEAREST WELL 1C),0 'f' ft FOUNDATION SCi It PROPERTY LINE R 1 HEREBY CERTIFY THAT 1 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 24 HOUR AD NC 'NOTICE. REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 /JJ=--+-�� TITLE l GLt f'Y�G 1�1�o n DATE�O "" dfi SIGNED `' C T 0.1 NEI I Q IN O N H H 1 n # + DEPARTMENTUS NL Applicallon AcDate b,S Area Employee ID# 6 1 Final Inspectioncepted Date lV ❑ SPECIAL PERMIT -Approved by Character of Soil to De of 3 Ft: A Pit/Sump Soil Character: COMMENTS PE SC Received Amount Dale Permit/Invoice # Permit IDN Code IN 13Cash Remitted Service Re ueat # N� 3 8S 2 o Q5 R 0b44 42.02-001 ONSITE WASTEWATER PERMIT 12/22/2003 F1 /q