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ONSITE Vk*,,3TEWATER TREATMENT S,,IIIIIIITEM 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 EXPIRES 1 YEAR`FROM DATE ISSUED JOB ADDRESS L2 ( ( KQ1--I� ..ti CITY/ZIP r 1 - J Z �[ CROSS STREET _,�jj( �A.�.�- 'I�c1. Q 4 e j APN 051-��1�© -�� PARCEL SIZE L � •O �t OWNER NAME ir s.}r-P C_e, 611 P- N (' 5' t- T r /� PHONE-?09' L-//�'U �(.3� r OWNERADDRESS Z 7 / J��s+t,- 6,^� kms^ (Jr CITY/STATFIZIP J� —& In C-- rol CONTRACTOR a C'. P�.-..,.�� A_ C L- H PHONE —0 7 CONTRACTOR ADDRESS r. CITV/STATE/ZIP f2jNe ,t LICENSE ❑C-42 C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION 24 REPAIR/ADDITION CI ENGINEER DESIGNED/A[❑ REPLACEMENT ❑ DESTRUCTION 1 INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: - LL NUMBER OF BEDROOMS: Z 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) \\ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES Z1 R n. DISTANCE TO NEAREST WELL _ ft FOUNDATION rlL_ft PROPERTY LINE El FILTER BED WIDTH ft LENGTH R DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH R LENGTH 12 DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SUMPS WIDTH R LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It DISTANCE TO NEAREST WELL-� ft FOUNDATION It PROPERTY LINE ft v }� SEEPAGE PITS NUMBER Z Wlorx !STe .� ft DEPTH 0 DISTANCETO NEAREST WELL ttQ ft FOUNDATION ZJ` ft PROPERTY LINE It I HEREBY CERTIFY THAT I 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. )� MIN(hMTUN 0 )UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9S3-7697 / �y SIGNED _ L \ 11� .�- TITLE MV--),tr� et+2/ DAI J6 � C) n or Nly EN TAI EP kill r .� EPARTMENT U.S 'LY glj,C Applicatio Accepte -- _ Date ( Area . Employee ID# `7/ Final ins tion B Date ��O r ❑ SPECIAL P IT-Ap rove by Character to De t of 3 Ft: Com- Pit/Sump Soil Character COMMENTS PE--- SC Received Check#/ Amount Date Permit/ Invoice# c_Wit Code INFO B Remitted Service Re uest# 12-01-001 ONSITE WASTEWATER PERMIT 12/22/2003