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R ONSITE WASTE -t;R TREATMENT SYSTEM MIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTU DEPARTMENT 304E WEBER AVE -3"' FI -STOCKTON CA 95202 - (204)468-3420 , II NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED $ FCROSS SS Z2� �. ��C��^'+t-� s � CITY/ZIP --f E:.'y C' rM r ` a EET N� APN (D q 2-o�C� PARcEL SIZE /G ° F � H , Cv\e M � PHONE M1IE _ OWNER ADDRESS ! •v• x 1 ^� C1,FY/STATEIZIP �l�_'�Cti�S SCK 4f �J CONTRACTOR PHONE CONTRACTOR ADDRESS _-� Y 7. y_ '�� ` CITYIS'TATE/ZIP `,I L.K/I j LICENSE ❑C-42 C3 C-36 OTHER C ' Y NUMBER96 2 2— EDATEIRATION DATl 2 D WATER TABLE DF.miv IM It C.EOGRAPiI[('AI,INI:ORNIA'I'ION: Coordianles X Y � LANDUtihAI'I'1.4C'AT'111Nlf �!'� - �-�� y 1'[:RC'I'ES'I'(S) NUMm:R S TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGIN'EERDESIGNED/ALTERNATIVE ` ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUM t-OF B6DROOM1IS:—� NUMBER OF EMPLOYEES:ElG t [.] SEPTIC TANK TYPEIMFG 'P'Af Y�, ,' gal 9 O COMPARTMENTS - i. r � 'i PACITY ri gal #OF COMPARTMENTS 13 GREASE TRAP TYPEIMFG 1 © PKG TX PLANT DISTANCFTO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE R f ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) C, ❑ LEACH LINES ❑ LEACHING HAMBERS #OF LINES LENGTH OF LINES ft . DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft , FILTER BED WIDTH I ft LENGTH fi DEPTH tt I DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH II ft LENGTH _ft DEPTH ft li� l DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 1t T ❑ SUMPS WIDTH i ft LENGTH it DEPTH ft R DISTANCE TO NEAREST WELL ft FOUNDATION ft' PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH— ft (rI DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft ❑ SEEPAGE PITS WIDTH i ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft Q 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. i IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED � � TITLE Pl' I^'t+f` DATE r �I. 07 - I 1 3 G •tP h f' DEPARTMENT USE ONLY Application Accepted Employee lD# 5 .`)C-67 Final Inspecon By Date GYa/h.'Ti� �[��SPECIAI PERMIT-Approved by Character o Dep of 3 Ft: Pit/Sump Sol[Character: COMMENTS 3 22-05 C'A °" pilei-OFCatIoiU 9,9�w PE SC Received h' Amount Permit) Code INTO IS C/as4ll Remitted Date Service Request# Invoice# Permit IR# �-2.7 7� `j !-•$ /Y i � �'f' C— RC1 7��..,,,,,, -- + 'I � ONSSTI: -I`M eI=R PERMIT 42-01 o� 1�S moi.7 e��v � ,o 1212102 ��5'>�. «,/_i- %.c yrs/✓^1 y /. , r a .