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Iia L�i1 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3Y°FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPE(.'TIONS EXPIRES 1 YEAR FROM DATE ISSUED ` JOB ADDRESS �;�--C. '1 v -- c` CITY/ZIP /,\; ._.1 1, -)1 cryo\ } I CROSS STREET �-- �' C 11' `' i r`J`, APN PARCEL SIZE OWNER NAME l-1 ti V'AC I \1u�Ln ...1 N Ltj V PHONEIaas OWNER ADDRESS !-'l"'' I� o a i C "'! rz J CITY/STATE/ZIP -4'P" ' H CONTRACTOR ICA APHONE "`•\.i 7 "`" CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-42 O C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y _O' PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# - 71 TYPE OF WORK: ❑ NEW INSTALLATION C) REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTICTANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS ` ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LME R ❑ LIFT STATION Size TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) al,a ❑ LEACH LINES ❑ LEACHING CHAMBERS #of LINES LENGTH OF LINES R DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R ❑ FILTER BED WIDTH R LENGTH R DEPTH fl DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R ❑ MOUNDED WIDTH R LENGTH R DEPTH R DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE fl ❑ SUMPS WIDTH fl LENGTH R DEPTH R DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE fl ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH ft IIA DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE fl ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R I HEREBY CERTIFY THAT 1 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. %IIN I N11%1 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2(19)953-7697 ++ 1 1 SIGNED �Y-'�c-'"\.-"' - fv"-__...�'1---" TITLE L�'r< -� DATE 6. 1AAA I \ h 1 C { T _ r ( ic•C ; ; - I 3 INu ll its T MEHL- ilt ft DEPARTMENT USE OILI' Application Accepted By.. I V�, - Date ''i -� fi Area Employee ID# ' FinI al Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: PittSump Soil Character: COMMENTS PE SC Received Check#L Amount Permit/ Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# 42.02.001 ONSITE WASTEWATER PERMIT 12/22/2003