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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3N'FL-STOCKTON CA 95202-(209)465-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS//J//�e- f,- CITY/ZIP CROSS STREET ) ��2�/J/�{ All ICS'- 04-0 - 7 PARCEL SIZE 1 -10. V y OWNER NAME S/Y=7r,l` f`7iO! ,ln_�C/� PHONE «yy� OWNER ADDRESS ,y'�, �- CITY/STATE/ZIP (� / �rC�'� t r•r CONTRACTOR �i ' / /-L%/-fC%�� CIL/' PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE OCA2 ❑C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# _ TYPE OF WORK: ;1- NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ^l NUMBER OF EMPLOYEES: .� ❑ SEPTIC TANK TYPE/MFG CAPACITY J- ^L gal #OF COMPARTMENTS ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LINE R ❑ LIFT STATION .SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES ❑ LEACHING CHAMBERS #OF LINES S` LENGTH OF LINES DISTANCE TO NEAREST WELL �c-IJ�T l FOUNDATION ft PROPERTY LINE R ❑ FILTER BED WIDTH ft LENGTH it DEPTH DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH R LENGTH R DEPTH it DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R ❑ SUMPS WIDTH R LENGTH R DEPTH ft z DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE it ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH_ ft DISTANCETO NEAREST/ WELL ft FOUNDATION ft PROPERTY LINE ft \ / SEEPAGE PITS WIDTH T ft LENGTH R DEPTH til fl DISTANCE TO NEAREST WELLf cO'f• R FOUNDATIONf R PROPERTY LINE R 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNT%'ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. M MUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED .i i TITLE G � DATE 4341 S P h -T. l L L I/ fu- /2. H; ITH SER CE —F3\'1R 'NITI 404 I L tl DEP RTMENT USV6NLY '7 ' Application Accepted B v Date 3 -3' -3 Area /- Employee ID# 514-+ _(/�, Final Inspection A - Date ��l ❑ SPECIAL PERMIT-Approveclby - -- Character of Soil to De Of 3 F(: Pif/Sump Soil Character: COMMENTS I&N SA Of PESC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B• as Remitted Service Request# 1-11 , 2- -7 0 1 4 5/31103 S OC 33 2.q LQi°ZQ, l�uccoilr 4o7yW7 ztuc - L�/�r -. - Sam•• .i_.