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3- ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS J~O� ✓� f/ �7,Ii-' of C1TY21P P r rI CROSS STREET r''n, Jan/,•-S _ _ APN `05-O�Q I7 PARCEL SIZE ol, Z a OWNER NAME �` PHONE b�%_7-�r�f U OWNER ADDRESS�+ / / CITYISTATE/ZIP CONTRACTOR �'�j1 1/ ��/ ��/ r- �- PHONE ei�"^� / tl CONTRACTOR ADDRESSL? e� CITYISTATEIZIP Jn7/<�,�C��.� ✓_ -�Jr') LICENSE AC-42 CSC-36T OTHER � NUMBERR>O//�� EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y N L PERC TEST # I BUILDING PERMIT - O _LAND USE APPLICATION#_-O- -1 O I TYPE OF WORK: NEW INSTALLATION -i REPAIRJADDITION ❑ ENGINEER DESIGNED(ALTS++RNATIVE O REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM Il DESTRUCTION 3 INSTALLATION WILL SERVE: i 1 RESIDENCE COMMERCIAL ❑ OTHER �+1 NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: \\ NUMBER OF EMPLOYEES: {i - 14 SEPTIC TANK TYPE/MFG / CAPACITY /S G U gat #OF COMPARTMENTS 1 ❑ GREASE TRAP TYPE/MFG CAPACITY gal #CF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE G � � LIFT STATION SIZE TYPE OF PUMP-1, c Cl PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES D LEACHING CHAMBERS #OF LINES 'Z— LENGTH OF LINES 11 O tl ft DISTANCE TO NEAREST WELL Z�?'f ft FOUNDATION ''Z ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft (3MOUNDED WIDTH ft LENGTH ft DEPTH y ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE +�+ ft ❑ SUMPS WIDTH • ft LENGTH ft DEPTH 7 ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH IT DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE I ft pu SEEPAGE PITS NUMBER �z WIDTH 5�" __-ft DEPTH--Z-C-' It DISTANCE TO NEAREST WELL _ C7J'rz_It FOUNDATION�Oft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, I STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. e MINIMYM 24 HOUADV NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76997 G SIGNED a �� TITLE��', /� DATE/•^L�>`•��7 a I I I E ITI y t SAI I �+ 111^01 CC UN HEAVI ON 1 ALS LT DE RT.EN 1 4 QE ARZM-E N T-P Sf O 1Y.1 r Application Accepted By Date Area Employee ID# FInaI trispectloh 8 y Daw-t n� --�}O SPECIAL PERMIT-Approved by 9 Character of Soil to epth of 3 Ft: Pit/ ur p Soil Character: M COMMENTS C_ PE SC Received Check#! Amount Date Perrndl Invoice# Permit ID# I Code . INFO B Remitted Service II # o ' N �� y ONSITE WASTEWATER TRTMNTSYSTEM PERMIT 1