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GAJ = U- tL ONSITE WASTEWATER TREATMENT SYSTEM PERMIT I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 NON-KEFUNDABLE PERMIT I.ALL LU`J U0.f-/0`J/ FOR INSPECTIONS tXXPIIRES I TEAR FROM UATE ISSUED JOB ADDRESS N 9 9e- CITY/ZIP A7CIkmp1' V 9Y7-7-0 CROSS STREET f"'„N� Ap �OS� (ie0-I -r t RC L$ E 3°(w 1�(�oF��E►"'r cK LV C P E' OWNER NAME OWNER ADDRESS�SN 3 yW)l6STATE/ZIP A GA -M p 0 CONTRACTOR 1-WIF Q1NV-- NV�� PHONE CONTRACTOR ADDRESS 40 W • 0' p ` -V- 9CITY/STATE/ZIP L•O1✓ ( CA LICENSE ,C-42 C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # 1 BUILDING PERMIT # LAND USE APPLICATION TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL 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 ft FOUNDATION ft 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 ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 114 le I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANC E�i STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. I M ,NOOHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED / � ` TITLE DDNS VL:i-A IV i DATE 3 - r - pit Do JAW l • �� D a, - 'a. F DEPARTMENT aSqmp � Application apt Date 2Area Employee ID#i �0 /�� Final Inspection - DateI SPE AL EMIT - Approved by Character of Soil to ep�thof, 3 �Ft: _ 9haract`e�r: COMMENTS PE SC Received Ch Amount D to Code INFO C sh Remitted Permit/ Invoice # Permit ID# Service Re uest# ONSITE WASTEWATER TRTMNT SYSTEM PERMIT �\f f S V L EA