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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 • ANON-REFUNDABLE PERMIT {� CALL 209 953-7697 FOR INSPECTIONS TS EXPIRES 1 YEAR FROM DATE ISSUED • JOB ADDRESS 65 1Q1 C�^ , TV/p P/A-IV LC A/. CITY/ZIP 7 I V11511-f-morli N C 11 A In �J� y � CROSS STREET _SDL AA I 1""r &IAC-�+ APN 0O (V �IO- ZD ,PALRCELSIZE S-•,+ Ac• Q OWNER NAME ✓V Z ^� ��T'✓7V - I ( PHONE I-E)33 OWNER ADDRESS US-91 C. FTPPIAivo LN . CITY/STATE/ZIP r�✓�GKTa ✓rT �Z(Z, CONTRACTOR D r IL �0E&/V��0 Nm EAJTA L- PHONE 3('I -o p �/ CONTRACTOR ADDRESS 14,04 w' O Au- T• CITY/STATE/ZIP ��✓� �-T I S Z'T p LICENSE ,C-42 :C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y on Y. PERC TEST # ZI FBUILDING PERMIT# LAND USE APPLICATION#12 TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION ENGINEER DE IGNED/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) Q L3LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 7?r I E3FILTER BED WIDTH It LENGTH ft DEPTH Ai,%,$ —v DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE (+� 1�'f/t ❑ MOUNDED WIDTH ft LENGTH ft DEPTH " /V — �ft 418 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH r A OU/V 7 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft ✓1�,� DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER VI`,iDTH ft DEPTH ft DISTANCE TO NEAREST WELL , ft FOUNDATION ft PROPERTY LINE ft 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. MINIMU HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE GONSVL-,-N^j DATE qtr �r- 71 x t- EPARTMENT U O Application AccABy Date Area Employee ID# Final InspectionDate Z $PE AL PERMIT-Approved by Character of SoiPit/Sump Soil C aracterCOMMENTS r Y J laC rG�e C e PE SC Received hec Amount Date Permit/ Invoice# Permit ID# Code INFO B ash Remitted erviceRequest# 6S K '7q Ij 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT