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t� ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS I.- d PA 1) CITY/ZIP I-OD/ �s'z�¢2— LA CROSS STREET W OP/D 0 2 I D 6E APN O,1/ -/70-.2 z PARCEL Slu OWNER NAME PHONE j�/J 2090 3`y{-fZ4.-2- OWNER ADDRESS 2-026CTY/STATE/ZIP�i CONTRACTOR � `'. PHONE, CONTRACTOR ADDRESS_- C 7 !�- CITY/STATE/ZIP LICENSE 0 C-42 ❑ C-36 OTHER NUMBER ExPIRATioN DATE WAT RTABLE DEPTH:,O\-2 J }2 GEOGRAPHICAL INFORMATION: Coordinates X Y Vl { PERC TEST # BUILDING PERMIT# LAND USE APPLICATION TYPE OF WORK: ❑ NEW I`iSTALLATION 0 REPAIRIADDITION D ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WIL.LSERVE; ❑ RFSInvrwE ❑ COMMERCIAL Ll OTHER , NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMB3R OF EMPLOYEES: ❑ SEPTICTANK TYPFJMFG_ CAPACITY g2.1 #OFCOIVWARTYIENTS ❑ GREASETRAP TYPE/MFG CAPACITY gal #OFCG-MPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LNE R 0 LIFT STATION SIZE TYPE OF PUMP O PKGTx PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) O LEACH LINES O LEACHLNG CHAMBERS #or LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft O FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL_ ft FOUNDATION R PROPERTY LINE ft O MOUNDED WIDTH ft LENiTH ft DEPTH It DISTANCE TO NEAREST WELL_ R FOUNDATION ft PROPERTYLNE ft O SUMPS WIDTH ft LENGTH_ ft DEPTH ft DISTANCE TO NEAREST WELL _ft FOUNDATION fl PROPERTY LINE R , O DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LM ft ❑ SEEPAGE PITS NUMBER WIDTH _ ft DEPTH ft DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft I HEREBY CERVft THAT i HAVE.PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN'JOAQUIN COUNTY ORD CES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIM R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE_D!d/✓E�. DATE /0-/Z,-a7 i I Ir I I 7 I I L / I, r ri= MET 4-1 A 1 DEPARTMENT USE ONLY Application Accepted By �'+- "�� Date Area Employee Final Inspection P. Date /ff0 SPECIAL PERMIT-Approved by Cbaraeter orsod to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS- � (.1e(Rs71 Y1/P'dki CD /. / COIZAA - i PE SC Received h Amount Permit/Date Invoice p Permit[D# Cade Info B Cash Remitted Service Request# -0 �.