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ONSITE WA, -EWATER TREATMENT SY' EM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBE`k-KVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT /, / 1 CA1LL 209 89533-7697 FOR INSPECTIONS (E�XPIR(ES 1 YEARN FROIM DATE ISSUED JOB ADDRESS l u N.14-J, I-T 14 I�T W!.%t�/ l / CITY/ZIP_ ) 2 C kf>h Z'A ? Z �/ II n o n CROSSSTREET ?- H/Vt�Q So(�E'L-44, !'LInIML&L--�APN OeI�' `/O�3pC1 /y !PARCEL\SIIZQE 0-J�f <CC p OWNER NAME .)N C,G- _ Re, /J��;+ (• yle-�. � F7]JG pHP�r CPHONE' (2-y5 ) r ✓ I ` D/o/ A OWNERADDRESS Sp�c2_ CITY/STATE/ZIP CONTRACTORCCI I Sel>{- PHONE �_ 5 CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# 0 0 D 0/0/ LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION 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 L' / CAPACITY / gal #OF COMPARTMENTS GREASE TRAP TYPFJMFG / I U / CAPACITY � 2zO gal #OF COMPARTMENTS 2- 0 ❑ PKG TX PLANT DISTANCETO NEAREST: WELL /0U t it FOUNDATION It PROPERTY LINE ft Cl LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES t, DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH R LENGTH I1 DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH it DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH it DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R ❑ DISPOSAL PONDS WIDTHft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION fi PROPERTY LINE R 1 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. :11NIMl.lnp 2 O R ADVANCE NOTICE REQUIRED FOR INSPEC IONS-PLEASE CALL(-2,091.).953-7697 SIGNED aLP' - U— TITLE, �CY� V'/I.4" rI�W1 DATE Z� C9ti .. .! 4 ... t...� } -.. Ae , T. noun -i , I ; . . . —fi=r•— ..� .{. { L,Q(yI/�'f{fai� IMa: 1 j 4 4 I k 1 � F I } i I + t , 1 T I +j 1 ff�{ / ` \ W E E DEPARTMENT U E ONLY ...3 Application Accepted Date _3 2-?-tV Area Employee ID# 5-1 q Final Inspection y Date ❑ SPECIAL PERMIT-Approved by Character of Soi to De th of 3 Ft: Pit/Sump Soil Character: COMMENTS S.tis7�at�1"� C C_ fls� /� .2( � ✓L Films nJ� I 11 �HE^/ UNL�� bm�4A,45-/1p,?C c L4�7� ��"<!t� /.sit) G Lam)l�7 /7l�✓l�� it/O !��/� `E SC Received eck#/ Amount Dale Permit/ Invoice# Permit lD# ie INFO as Remitted I Service Request# S is ,moi O -1' ,i`.co o:?Z J Vr 7 ONSITE WASTEWATER PERMIT