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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1W East Hazsfton Avenue-STOCKTON CA 952054232-(209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED iJOB ADDRESS 1 H 0 1 /� PwerJ u n r,A CrrY/LP .S to(- 4-0M S 2 IF i�+ CROSS STREET RV, � ^ �1' API O8'g�/ i0 PARCEL Sig � OWNER NAME R t� y'VAIL�J ' �J-Il..'4CJ PHONE 2 o y- 99G• �i7Y6 r OWNER ADDRESS // I L'0I( ✓L 1 6L44c rf O o CrTY/STATFJZIP X CONTRACTOR C ' V ' O PHONE 2o/�t/�• �J�,.� I C CONTRACTOR ADDRESS 3 10 Q Ta 'f< <+s'T (/+ CRY/STATIE" L(�O�t•)'T 6 LICENSE C�42 .C-36 OTHER NUMBER `-' 2-1 EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y EPI RC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPABt/ADDnnoN - ENGINEER DESKINED/ALTERNATIVE REPLACEMENT DESTRUCTIONXI'YIK— 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 COMPART%I-rNTS DISTANCE TO NEAREST: WELL it 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 ft DEPT- ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH ft DEPTM. _ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE To NEAREST WE-L R FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER MOTH ft DEPTI, 1t DISTANCE TO NEAREST WELT ft FOUNDATION It PROPERTY LINE ft 1 HEREBY CERTIFY THAT I HAVE PREPARED TWS APPLICATION AND THE WORK WRL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 p SIGNED TITLE QW I%1 c4!^ DATE 10--f-N� - ire T-. ! i i - — - DEPARTMENT E OPLY Application Accepted By Date 1V Area Employee ID# `„ t: Final Inspection By -_ Date I SPEC LIT-Approved by Character of Soil to Depth of 3 Ft: mp Soil Character: COMMENTS rPE SC Received Amount Date P«Tnw Invoice# permit IDO Code 1 INFO B Remitted Service Request 0 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 10i4:07