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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAWN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202.(209)4683420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS .39 9 5 C• Of 4-HT M I L.r- XD . clTyroP L-011>1 , (�{ S�4fD CROSS STREET /�Irm c'KE f�01/E R . APN yl 9-)4o �.7 �P(ARCE�LL SIZE t J `rrC OWNER NAME ptptM rf• D+if 1 TI-1 P.— T7-J-T(oIT OWNER ADDRESS 7�i C • y&+IT m i L 9-r. cmBTATE21P L.01>1. CA ` S 240 coimcmR LIVE 0AV— CS•E0E.NV1K40M6f-J I AL PHONE 3109-031-5 CONTRACTOR ADDRESS &fo-+ IrJ• 0 AK- ST. CITYISTATEpZP LICENSE 1,IC-42 LJCAe OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Cowdlnates X Y PERC TEST # BUILDING PERMIT MLAND USE APPLICATION#_-___________ _ TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIWADOMON 0 ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RSIDEKCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LMNO UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPEIMrG CAPACITY gal #OFCOIQARTMENT9__ ❑ GREASETRAP TYPEIMFG_—___ ---__- CAPACITYgal #oFCOMPARTAENTS_____ DISTANCE TO NEAREST: WELL ft FOONDATION ft PROPERTY LINE.---ft O LIFT STATION SIZE TYPE OF PUMP 0 PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES U LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL_____it FOUNOATKN__—__ft PROPERTYLNE___ _ft ❑ FILTER BED Wom R LENGTHft DEPTH___ R DISTANCE TO NEAREST WELL it FOUNDATION` _ft PROPERTYLINE ft ❑ MOUNDED W®TN----ft LENGTH _—_--ft DEPTH! it - DISTANCE TO NEAREST WELL_-----It FOUNDATION—_--�—It PROPERTY LNE -ft ❑ SUMPS Wam__ _It LENGTH ft DEPTH—A it DISTANCE TO NEAREST WELL____—__it FOUNDATION----------4 PROPERTY LINE _ _It ❑ DISPOSAL PONDS WIoiN ft LENGTH-------ft DEPTH_ _ It DISTANCE TO NEAREST WELL__ _It FOUNDATION _it PROPERTY LINEft ❑ SEEPAGE PITS NMgBt YVStTN ________ It DEPTH__ ft DISTANCE TO NEAREST WELL__ ft FOUNOATN]N_______ft PROPERTY LnE___ ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, r STATE LAWS AND RULES AND RE(IULATION2 OF SAN JOAQUIN COUNTY. IN U UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7897 'L SIGNED__ATITLE C•o)%SL)C.-TANT DATE VIC ENT 2'F �D13 MIL— JIM COUNTY OMENTAL EPARTMENT DEPARTMENT USE ON Y E- 1� ^ Area Employee I(3# Application Accepted By�L- � /J2� Date_�].�� Final Inspection By __ Date___ _ ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of S Ft: PWSump Safi Character. COMMENTS PE SC Roeelved Choctafr Amount Permw Invoice# PermR IDS Code ItIFO 8 Remittetl a Service,R uest# ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 42-0t 1014/07