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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 1 YEAR FROM D TE ISSUED JOB ADDRESS �� ` �I Z C' rl CITY/ZIP d� A P CROSS STREETf ;�J(]�J APN �j��f�(� O PARCEL SIZEC ��` p OWNER NAME 1�F- G/V i� V / �/ PHONE - U C V G� - I OWNER ADDRESS _ CITYISTATEIZIP CONTRACTOR LW 4 O7 PHONE _I/ CONTRACTOR A I ADDRESS 7 CITYISTATE/ZIP r /V' ,h LICENSE C-42 _,C-35 OTHER NUMBER r 5 �4151f` EXPIRATION DATE - CJ WATER TABLE DEPTH: _ ft GEOGRAPHICAL INFORMATI Coordinates X Y Q U I CPERC TEST # J BUILDING PERMIT# - LAND USE APPLICATION# J I TYPE OF WORK: NEW INSTALLATION C REPAIR/ADDITION 1 ENGINEER D SIGNED/ALTERNATIVE I REPLACEMENT [: OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: 1 R IDENCE COMMERCIAL 1 OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: /J , SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS v '❑` GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES �IJ ft DISTANCE TO NEAREST WELL I batt FOUNDATION ft PROPERTY LINE R ❑ FILTER BED WIDTH ft LENGTH ft DEPTH it DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ DISPOSAL PONDS WIDTH ft 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 ft PROPERTY LINE ft 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. MINIM M 24 H UR D CE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL 209 953-7697 "� cam_ TITLE r 1 Y4� o r DATE -7 SIGNED /C'��'z �-�--� - y / J +b l l. EPARTMENT SE ONLY Application Accepted By Data C� Area _ employee Iu8 � Final Inspection By Date 5 SPECIAL PERMIT -Approved by Character of Soil to D th of 3 Ft: 100, ump Soil Character: COMMENTS of /L� _(j�� Lj� � IE2 X11;11 /r�f�llfl/U GIP t�1 lJ� Leh - PE Re ved Check Amount Date PermiU Invoice# Permit ID# Code INFO Byj Cash Remitted Service Request# _— r� i 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 9/27/70