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ONSITE WASTEWATER TREATMENT SYSTEM PERIA . SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E lV£RER AVE-3M'FL-STOCKTON CA 95202 - (209)465-3420 F NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES t YEAR FRoM DATE ISSUED ? JOB ADDRESS F Gc: �r•�r' -"—+t� CITY/ZIP r s t� - CROSS STREET Z� ('�IAfI/ �-1 �"f��;`��5+'�APN 1 (�J ��[g C) � �"�� PARCELSIZE OWNER NAME k)l Gf�L� I`1'�E�`V'1 �t/r. ^n !PHONE j ,A OWNERADDRESSI c�� ` a�.�1 +-�pp' �[��f' 14✓ CITVISTATE/ZIP CONTRACTOR '1 ,J/�� 4Z. tyn-� T�'t a L-a^/ PHONE` CONTRACTOR ADDRESS- A,rl ().X, Id��S� CITYISTATEIZIP �L.'L'iLj-LA e-qt !^, LICENSE ❑C-42 ❑C-36 OTHER NVM1IBER } EXPIRATION DATE "'J, V" !1i WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y L ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE rte" ❑ REPLACEMENT ❑ DESTRUCTION � rll INSTALLATION WILL SERVE: EsmENCE ❑ COMMERCIAL ❑ OTHER 1 rl yy NUMBER OFL[VINC UNITS: 1 NUMBEROF BEDROOMS: l NUMBER OF EMPLOYEES: C1-`SEPTIC TANK TYPFJMFG r �i"'� CAPACITY j}(� gal }'1 OF COMPARTMENTS_ F ❑ GREASE TRAP TYPE/M FG CAPACITY gal #OF COMPARTMENTS } t _ � ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL I C�:� ft FOUNDATION J.5 ft PROPERTY LINE -"j 1 ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR{ENCLOSED SYSTEM) It J LEACH LINES ❑ LEACHING CHAMBERS k OF LINES y'�. LENGTH OF LINES - DISTANCE TO NEAREST WELL _I�ft FOUNDATION ] J�'t ft PROPERTYLNE ❑ FILTER BED WIDTH ft LENGTH ft' DEPTH }} DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl ❑ MOUNDED WIDTH A LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATFON ft PROPERTY LINE ft (3 SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE fl ❑ DISPOSAL PONDS WIDTH _ ft LENGTH ft DEPTH_ h DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE R a SEEPAGE PITS WIDTH- - ��,11 ft LENGTH --.)DEPTH � i I ft F.-I DISTANCE TO NEAREST WELL r D_C,Y ft FOUNDATION r ft PROPERTY LINE�_t�__ fl 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL DE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNT/'ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMIJ 29 HODR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2091953-7647 / 1 SIGNED TITLE L.�,iTi 14 L f� DATE r ' ac I s G J S E " , t. -371 n, v 4 I DEPARTMENT U E NLY Q /f Application Accepted By Date Area / Employee I D / rFinal Euspection By Date ❑ SPECIAL PER—MIT-Approved by Character of Soil to D th of 3 Ft: Pit/Sump Soil Character: l,COMMENTS 4. C {� ,F PE SC Received Chec l•1 Amount Date Permit! Invoice# Permit lD# d Code IN BY Cash Remitted Service Request 0 -1 0 S2dC) 3L�' I 42-01-001 _-IVV02 ONSITE WASTEWATER PERMIT