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ONSITE WAEWATER TREATMENT SYM PERM§CANN& 4. 5 SP.PTUAQUIN COUNTY ENVIRONMENTAL HEALTh.✓EPARTMENT 304 E WEBER, - JE - 3"° FL - STOCKTON CA 95202 - (209) 468-3420 NONE -REFUNDABLE PERMIT _;, ; CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED LICENSE ❑ C-42 JOB ADDRESS Z a_ EXPIRATION DATE WATER TABLE DEPTH: _- - R GEOGRAPHICAL INFORMATION: Coordinates X y PERC TEST # CITYIZIP LENGTH OF LINES _ LAND USEAPP,LICATION # ?A, 0 U � y CROSS STREET _. -_ _ ✓ p��1' 1^( 7 tiOAPN 0 0 PARC L SIZE ft PROPERTY LINE ❑ REPLACEMENT ❑ DESTRUCTION [ ❑ COMMERCIAL ❑ OTHER vV e OWNER NAME TYPE/MFG PHONE gal # OF COMPARTMENTS ❑ GREASE TRAP OWNER ADDRESS " V {/� r" � w C[TY/$TATE/ZIP ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL + y CONTRACTOR ❑ L11FT STATION SIZE TYPE OF PUMP ft FOUNDATION ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ SUMPS WIDTH ft LENGTH PHONE CONTFACTORADDRESS CITYISTATE/ZIP - LICENSE ❑ C-42 ❑ C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: _- - R GEOGRAPHICAL INFORMATION: Coordinates X y PERC TEST # -2— BUILDING PERMIT # LENGTH OF LINES _ LAND USEAPP,LICATION # ?A, 0 U TYPEOF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED IALT RNATIVE ft PROPERTY LINE ❑ REPLACEMENT ❑ DESTRUCTION INSTAILLATION 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 ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL + ft FOUNDATION ft PROPERTY LINE fl ❑ L11FT STATION SIZE TYPE OF PUMP ft FOUNDATION ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) it DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE JSAL PONDS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE AGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE I • 1 •• 1 1 •' 1. 1 1 • ■■■■■■■■■■■r■■ ® ■■■■■■■NEEM MEMEM■■E■M■N■■ ■NE■■■E■N■■NONE No MOEN ■■■■■■■■■ ■NE■■ ■■EM■M■■■■■■EN■ BEEN ■EMNM■■EE■■E■■E M■NO■■E■EEO■M■ o` ■N■■■■NE■EN■■■■ O■MENONE E■■■■■ ■■■N■■E■N■■■EM■ ■E■SEEM E■■■■■ Norm ■■■NEEM■■■■ ■■■■■■■■MME■■■ - ■■x/1NONE E■■■■■■■ ■■■■NEEM■■■■■■ ■■!I■NE■■■■MMMEN E■MMM■■■■O■E■■ ■■NI■■■■■NM■■■N■ ■OMI■■■■■■E■■E■ - ■■N EMNSOMEM■■■ ■OEM■E■■■NEON■ /a. ■EVM■ECZ:SMi'ammo■ ■■■■E■■■■■■■■■ ■■■NE■C.i'3n�'IIMi0■■■ ON MEMNON ME MEMO NEORREM EMSEME SOMEONE MOMENEWINUM BEEN ■EM■O■M■■■■NE■ NEON NNEEMl■TM"OOS■■S®■MONS■N■EM■NE■ ■■EN■EMN mig"E■■MENS■N■N■■M■■ NEM 1115Y�■■EMM■E■■■EMS■O■■■NENEONES■ENEENME■■■■M■E■ENONE 1 PE SC Received Check#/ Amount Date Permit/ Code INFO By ash Remitted Service Re uest # Invoice # Permit ID# 42-02-001 1 ONSITE WASTEWATER PERMIT 12/22d003I ft fl ft ft ft ft ft ft ft ft fl ❑ LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES _ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 0 MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH it DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE JSAL PONDS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE AGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE I • 1 •• 1 1 •' 1. 1 1 • ■■■■■■■■■■■r■■ ® ■■■■■■■NEEM MEMEM■■E■M■N■■ ■NE■■■E■N■■NONE No MOEN ■■■■■■■■■ ■NE■■ ■■EM■M■■■■■■EN■ BEEN ■EMNM■■EE■■E■■E M■NO■■E■EEO■M■ o` ■N■■■■NE■EN■■■■ O■MENONE E■■■■■ ■■■N■■E■N■■■EM■ ■E■SEEM E■■■■■ Norm ■■■NEEM■■■■ ■■■■■■■■MME■■■ - ■■x/1NONE E■■■■■■■ ■■■■NEEM■■■■■■ ■■!I■NE■■■■MMMEN E■MMM■■■■O■E■■ ■■NI■■■■■NM■■■N■ ■OMI■■■■■■E■■E■ - ■■N EMNSOMEM■■■ ■OEM■E■■■NEON■ /a. ■EVM■ECZ:SMi'ammo■ ■■■■E■■■■■■■■■ ■■■NE■C.i'3n�'IIMi0■■■ ON MEMNON ME MEMO NEORREM EMSEME SOMEONE MOMENEWINUM BEEN ■EM■O■M■■■■NE■ NEON NNEEMl■TM"OOS■■S®■MONS■N■EM■NE■ ■■EN■EMN mig"E■■MENS■N■N■■M■■ NEM 1115Y�■■EMM■E■■■EMS■O■■■NENEONES■ENEENME■■■■M■E■ENONE 1 PE SC Received Check#/ Amount Date Permit/ Code INFO By ash Remitted Service Re uest # Invoice # Permit ID# 42-02-001 1 ONSITE WASTEWATER PERMIT 12/22d003I ft fl ft ft ft ft ft ft ft ft fl