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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN-I' 304 E WEBER AVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT J/ I CALL(209)953-7697 FOR INSPECTIONS �EXPIRES I YEAR FROM DATE ISSUED /V JOB ADDRESS ��ls o r ('/T '4 1,wAw `19 CITY/ZIP ) ^ c k-t;PA, G A 9yz-f F -z- -7 jCROSSSIREST APN S.. 4 UwNF.RNAML ,�41 Cj�'F�.. r7Co2'4,T+ `lt►-LIn pit 10L. OWNER ADDRESS SQ'F�� CITY/STATE/ZIP �S 2 cel r CONTRACTOR Se-�r- PHONE 9(bS-S`o7 CONTRACTOR ADDRESS CITY/STATE/ZIP LICFNSE ❑C-42 ❑C-36 OTHrR NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST M BUILDING PERMIT# (7 O O cl'o/ LAND USE APPLICATION# TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DFSTRUCTION i INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NLMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ^^ CAPACITY Z gal 4 OF COMPARTMENTS GREASE TRAP Tv Pr.MF(i )J_ 1j,&-=7) CAPACCIY �r �yV gal #OFCOMPARTME\TS ? - ❑ PKC.TX PLANT DISTANCE rO NLARFST: WELL 0 U f ft FOUNDATION R PROPERTY LINT, ft ❑ LIFT STATION' SIZE_-- TYPE Or PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS P OF LINES LENGTII OF LINES ft DISTANCFTONEAREST WF.I.1. ft FOUNDATION ft PROPERTY LINE ft A ❑ FILTER BED WIDTH ft I.r.NGTH ft DEPIH ft C DISTANCE.TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH —_ ft LEN(iTH _ it DEPTH _. ti DISTANCE.TO NF.ARFST WELL ft FOUNDATION it PROPERI Y LINE ft ❑ SUMPS WIn'rH ---ft LENGTH �— _ _ ft i)FPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DT•PTH — fl Dist ANCET'ONFARESF WELL ft FOUNDATION _ ft PROPFRTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH _ ft DISTANCE TO NEAREST WELL ft FOUNDATION 11 PROPERTY I.INF, R I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAW'S AND RULES AND REGULATIONS OF SAN JOAQU'IN COUNTY. s IININIU 12IU IR ADVANCE NOTICE:REQIARE:D FOR INSPEC ION1S_ PLEASE CALI.(209)9$3.7697 _ SIGNED TITLE G lvt �1 �r%1 DATE �L C93 , r - ..__,.._.:....,._._...,!..._ .,�L..} ,.�. .a•�.. ..ter L .,..rv�l......1_..w„i.,,r•.._j—•-,,,,ju,,._... , , i I :+1 -w-.i- � )._•_. _.i 1-•- j I--1-. ♦ f., 7 1 d I � ! t _' I-y_'.l._-�---._i:.`: �1 5..._�.._E ._.,..-•!-;•,•_.{-._ ,.._.t-- ___-+•_ _�..T--r ,••rte: - , --�- 11 ' — — — p E E A DEPARTMENT USE ONLY j Application Accepted Dole iW _. Area Employee IDH S-7 Final Inspection y ��_v Date � ❑ SPECIAL PERMIT-Approved by Chancier of Soi to Dc th of 3 Ft: Pit/Sump Soil Character: COMMENTS --r4uST)4Lj-#n/(;"• I—T-6,2 ,0i AL F--.)Q- n/F�(,J g-c ry-H x/ U PE SC i Received tent/ Amount Date P Invoice N Permit IDM Code INFA -'ris Remitted I I , /nr�vice Re uest M 42-- !$ �O / 3 art .flD o92 5 V 42.02.001 ONSITE WASTT:WA'IFR PERMIT 12-12!2003