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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL TI DEPARTMENT '1060 East Hazelton Avenuc-STOCKTON CA 95205-6232-(209)468-3420 NON-REFUNDABLE PERMIT (� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS2`1. Z3 N' �Wj 99 CITY'zJP A(lftm? ) CROSS STREET /1,1` p .4PN D O�^1{�®� t ( PARCEL S�I/ZE p d OWNER NAME S�N�j�7i'}'2j CFI L(II�11I�At'�• P{H�O(�NtEr`�ZO�)�,3,tZ7`q-)Z 1:3� OWNER ADDRES(S�r L,./%r, N ttW� �� CITY/STATE21P \' '�`(FO (CA 2X CONTRACTOR Yt� OBI`` '- lNC' -df�yt0 DUI ( PHONE L��1 �` CONTRACTOR ADDRESS l-1 L-n�L�r+`(t!�� K�� ITS, /V�� CRYISTATE/ZIP 1'1•`��,EC M\� VV` LICENSE QC-42 QC-36 OTIIER Y7�� 1 (� NUMDrYltER "✓V�� ` EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPRICAL INFORMATION: Coordlnate5 X Y PERC TEST ;d FE BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: 0 NEW INS FAI_LATION 0 REPAUVADDITION �j❑ ENGINEER DESIGGN�ED�IALTERNATIVE D REPLACEMENT DESTRUCTION S gTrL - INSTALLATION WILL SERVE: ❑ RESIDENCE 'I COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BCOROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG _ CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY 901 1%OF COMPARTMENTS DISTANCETO NEAREST: WELL. ft FOUNDATION _ ft PROPERTY LINE —ft ❑ 1-117STATION SIZE TYPE*OF PUMP ❑ FKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) El LEACH LINES O LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH It LENGTH ft DEPTH ft DISTANCE-TO NEAREST WELLft FOUNDATION ft PROPERTY LINE —ft ❑ MOUNDED WIDTH fL LENGTH ft DEPTH._ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL —ft FOUNDATION ft PROPERTY LING ft '] DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL_ ft FOUNDATION ft PROPERTY UNE ft LJ SEEPAGE PITS NUMBER WIDTH ft DEPTH it DISTANCE TO NEAREST WEIR ft FOUNDATION ft PROPERTY LINE ft f HEREBY CERTIFYTHAT I HAVE PREPARED THIS APPLICATION AND THE WORT(WILL BE DONE IN ACCOKOANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL((220,901/9-53.7 7 SIGNED TITLE Pr�.ec, rA-GL1�-!(L>t,Q./' Iv✓'W DATE r I I ' NI ID I 3 Nry a r I 1LLIa I ' W -LL DEPARTMENT -- — DEPARTMENT SE ON Y Application A p y - Date � Area 41_FT7 Employee ID#__C-- `v Final Inspection Date Za. SPECIAL PERMIT-Approved by Character of Soil t epth of 3 Ft: Pit/Sump Soil Character: COMMENTS l�/_ ��i�j�Lt��i�� R�Y✓��l 7rf��/Cttr/� !� -� —Gu�1 �zr 4124U9-, - PE SC Received CheC101 Amount Date PermiU Invoice# Permit IDid Code INFO B -s Ramltted Servico Request N 0 / L) OS.a7 -7 OC(o__ SS7 ONSITE WASTEWATER TRTMNT SYSTEM PERM!"r d�-tt t