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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 NON-REFUNDABL �-E-PERMIT pd ,„SCALL 209 953-7697 FOR INSPECTIONS 1 EXPIRES 1 YEARFROMDATE ISSUED JOB ADDRESS 1 s T S I t= , i t'+. iu P-D• Cffy Z,1P IN`+T `�,76. s CRoss ST—T D� G�EIL APN 001 "0"f I PARCEL SIZE 5-11 OWNER NAME rAVL e A LCS.S D PHONE •��` Z 7 6 OWNER ADDRESS Z&4+'91 J hGK TOO N F- �-D, CRYISTATE/ZIP G{t11T� CA 't F(032 CONTRACTOR W""40-1 10.r`I4 OC+'Iy�.twll AVN Ea'�7 1 L- PHONE 10'602-03 257 CONTRACTOR ADDRESS "40-- w- O PC� 91. CITYISTATE/ZIP Ly%>1 r CA G/i S Z-4-o LICENSE- ,'C-42 _-,C.36 OTHER NUMaat EXPiRATiONDATE WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATKIN: Coordinates X Y PERC-TEST r BUILDING PERMIT# LAND USE APPLICATION# J TYPE OFWORK: _ NEW INSTALLATION1. REPAIR/ADomoN _. ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT - DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE D COMMERCIAL OTHER NUMBER OF LIVING LINKS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: O SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DIaTANCETO NEAREST: WELL R FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PUNT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES _ LEACHING CHAMBERS #OF LINES LENGTH OF LINES It DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R ❑ FILTER BED WIDTH ft LENGTH R DEPTH ft DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R ❑ MOUNDED WIDTH it LENGTH it DEPTH it DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE it ❑ SUMPS WIDTH it LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R ❑ DISPOSAL PONDS WIDTH It LENGTH R DEPTH ft DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH R _ DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R I HEREBY CERTIFY THAT 1 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. .r MUM ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE C nS*VL..T/l7-rr DATE AYMENT ECE11/E® C 0 7. 2014 AQUIN COUNTY VIROMENTAL H DEPAFrrMFI�} DEPARTMENT'/SE QNLY, Application Accepted By � DDatej,�r' S!L!-1/—A� Area y -C Employee I{7#(,��Le) Final Inspection By_ Data L' SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: PiUSump Soil Character: COMMENTS D/A PC,C, A vv_� SSS PE SIC Received ChecAmount Date PerrtdU Invoice# Permit ID# ode INPo B ash Remitted Service Ranuest# t)73 os fl 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 19/4107