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lie ONSITE WASTr/ATER TREATMENT,SYSTI")PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE =3 FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EX�IPIRES I YEAR FROM DATE ISSUED / JOB ADDRESS 17� �A7- 1A- HAA1T O n CITYIZIP'44A M'00 n?32 ZD CROSS STREET N D APN Oa7- 3 za- 17 PARC L SIZE Ip Ae— C / A OWNER NAME �NdQ« DIZcW!< PHONE 33 OWNER ADDRESS a&5 j,--.4 rT .IA kfA Aj-r gaA b _ CITY/STATE/ZIP C�I'�/��.C AJ _1, CONTRACTOR Nf u IY l PHONE (p ��14-a 3 CONTRACTOR ADDRESS C[TY/STATEIZIP Z.OGtCA 0095/ LICENSE ❑C-42 ❑C-36 OTH17R NUMBER EXPIRATION DATE WATER TABLE DEPTH: f' ft GEOGRAPHICAL INFORMATION: Coordinates X Y M PERC TEST # 02 BUILDING PERMIT# LAND USE APPLICATION#Y,4-dS --.5-"7 TYPE OF WORK: ❑ NEW INSTALLATION C7 REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) CA ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE:TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft r ❑ I+I1.'I'I:K IIID W1pFII fi LFN(NH DISTANCK-ro NFARES'1' WELL 11 FOUNDATION Il PROPERTY LINE 11 ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft 777 DISTANCE'ro NEAREST WELL. R FOUNDATION 11 PROPERTY LINE 11 ❑ SUMPS WIDTH ft LENGTH 11 DEPTH ft DISTANCE'1'O NEAREST WELL R FOUNDATION 11 PROPERTY LINE 11 ❑ DISPOSAL PONDS WIDTH ft LENGTH 11 DEPTH R DISTANCE TO NEAREST WELL f1 FOUNDATION R PROPERTY LINE f1 © SEEPAGE PITS NuMBER WIDTH R DEPTH 11 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 1 HEREBY CER THAT I HAV EPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY O ICES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. i NIM1 R ADVANCE NO'T'ICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 p of SIGNED TITLE r9�✓��R DATE _/^�Z--03 i� I I I A 4P P I El E 'r Q Y 5 t H D1r)AVO 1,4 DEPARTMENT USE O LY ! Applicalio Acce Date q -/2 � Area Employee ID# S3 C C' ff /ii r- J' Date ❑ SPECIAL PERMIT-Approved by FinallnsrctianBH �3= I Characle of-Snll to Del th of,l 1'1: PitlSump Sail Character: COMMENTS PE SC Rcccivcd Check#1 Amount Ptrrrsitl I', Dale �.er%ict R wu It IernktM Piarmif IDM Code lNFo IN RemlHed 3 SD o3 ,.1. r r 42-02-001 12122f2003d w� s -- 4�