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U ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMEr f�L HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 1'1UN-r%trUlNUAtILt rrrKMI I - / pL.ALL ZIUy yD3--10U/ FOR INSPECTIONS p CXPIKtS l TtAIR'F�ROM DATE I5SU JOB ADDRESS Z '1 / 4'1 7 - C.� AS M A IV 94•)' 1 CINT/ZIIP 'T 1'�AC1 j 'ISROT CROSS STREET , . `L ) y / \ /y ,�,�APN 6 /`��/ - y 0 O - 0'+ tP,ARCEEL SIZE pSLJ� OWNER NAME wpo '• 1 Qr_ - I VAtjf') y w„ wrttd ) T�PPHONE`,�41 SJ -'O - T�K OWNER ADDRESS ori C r ES /"V ' CITY/STATE/ZIP 1 '`M'I . CA 4 S 3—i - CONTRACTOR LI V 6 OPCN &e0 JV) PD/JMV_A ► f A L PHONE 3 LOCr - 6 3� rrr4"� - p p CONTRACTOR ADDRESS �-4 t)' ON K S I ' CITY/STATE/ZIP L�✓ I C / S LICENSE _ C-42 C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y X PERC TEST # ? BUILDING PERMIT # # OF LINES LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAWADDITION ENGINEER DESIGNED /ALTERNATIVE ft FOUNDATION REPLACEMENT ft DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER ft 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 It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 1 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. MINI 4 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953.7697 SIGNED TITLE�G '�9y14%411t DATE p Application Accepted By� Final Inspection By l Character of Soil to Delgh of COMWNTS '!>,7 irT- a IRTMEN E ON Date Area Employee ID# Date I SPE IAL PERMIT -Approved by PE SC Received Check#/ Amount Permit/ ode INFO By Ca emitte Date Service Re uest # Invoice # Permit ID# 7 SSS , 42-Ot ONSITE WASTEWATER TRTMNT SYSTEM PERMIT