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2w ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE - 3YO FL- STOCKTON CA 95202 - (209) 468-342 .a NON-REFUNDABLE PERMIT CALL 209 9533(-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE] JOB ADDRESS Zo $j Sm= i' CITY/ZIP�1'rUj-�(� CROSS STREET LJ—ylWt APN Z22. - .3r.t' ^ IC3 PARCELSIZE �• 4�+ OWNER NAMEyJ PHONE �r Z.-3 5 �r.T_EJ O OWNERADDRESS CITY/STATE/ZIP CONTRACTOR iT / /' - e,- PHONE.-S� —YS 3 CONTRACTOR ADDRESS 140 I /' . CITY/STATE/ZIP LICENSE ❑ C42 ❑ C-36 OTHER NUMBER 1. EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST q BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION 31 REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: D 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 ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL fl FOUNDATION fl PROPERTY LINE P ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES fl DISTANCE. TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE fl S FILTER BED WIDTH A ft LENGTH �L ft DEPTH 31 n DISTANCE TO NEAREST WELL t�rQ R FOUNDATION fl PROPERTY LINE fl ❑ MOUNDED WIDTH ft LENGTH fl DEPTH fl DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl ❑ SUMPS WIDTH ft LENGTH it DEPTH fl DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE fl ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH fl DISTANCE TO NEAREST WELL fl FOUNDATION R PROPERTY LINE fl ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH fl DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE fl 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. MINIMUM 24 HOUR ADVANCE NOTICE: REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953.7697 SIGNED TITLE ��J�l�•i�vc.+� i DATE J �!M r%O . CIS L t i Q N OA Ff R N R M DEPARTMENT IIS ON Y S Application Accepted B.<' Date /iJ Z% DS Area Employee 11 Final Inspection By Date ^� ❑SPECIAL PERMIT -Approved by Character of Sall to Dep of 3 Ft: Pit/Sump Soil Character: COMMENTS F/fT 2 8e J -yZ> Co,v7�l i�y �Qo�C . Fr o F m? o -IG . Ok `M t SS -Ltd SE.177C P rvtIT- /9 I;-:,2 GtT-IioF / tr3yTEti4 �.� _ An -4C -k,54 I— . PE SC Received Amount Date Permlt/ Invoice III Permit IDN Code INFO B Cash Remitted Service Re nest q II0L ro !ls �p 2so.uo 1\OS SOC' 42-02-001 n �,d'�\ ONSITE WASTEWATER PERMIT 12/22/2003 /f7