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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AYE-3" FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 09)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOHADDRESS 1 CI r-y/ZIP CROSSSTREEI' �/ /{ ' All r,7:)-3 -3 / PARCEL SIZE OWNER NAME f"x Sgrw&LID 6 V PHONE r( ( ✓5�/� OWNER ADDRESS 1{ C I J ' t i_�1'1 11 ._ _._Vb_ t l/ CITY/STATE/ZIPI,�_j,�t CONTRACTOR j •�- �'4�S 1 1 _� L 1��/ PHONE f: J._. , 7 CONTRACTOR ADDRESS r!-.% CITY(STATPJZIP LICENSE %C-42 0C-36 OTHER NLiMBER � EXPIRATIONDATC WATER TABLE DEPTH:_ h GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST M —� BUILDING PERMIT# LAND USE APPLICATION#.__ _ TYPE OF WORK: U NEW INSTALLATION REPAIRIADDITION ❑ ENGINEER DESIGNED(ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RF-91DENCE A COMMERCIAL7 ❑ OTIIEWf� NUMBER OF LIVING UNITS: t NUMBER OF BEDROOMS: 2^ NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPFJMFG CAPACITY gal 4 OF COMPARTMENTS _ O GREASE TRAP TYPFJMFG_ CAPACITY gal kOFCOMPARTMENrs O PKG TX PLANT DISTANC.F TO NEAREST: WELL _ , R FOUNDATION ft PROPERTY LINE. ft ❑ LIFT STATION SIZE-- TYPE OF PUMP ❑ SAND 011,SEPARATOR(ENCLOSED SYSTEM) LEACH LINES Ia LEACHING CHAMBLRS� E k GF LINES 1 J LENGTH OF LINES +0 R DISTANCE TO NEAREST WELL ft FOUNDATION + ft PROPERTY LINE �t R ❑ FILTER BED WIDTH R LENGTH ft DEPTH _ ft DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH -ft LENGTH ___ ft DEPTu_ fl DISTANCE TO NEAREST WELL ft FOUNDATION_ ft PROPERTY LINE R N ❑ SUMPS WIDTH [[ LENGTH _ fl DEPTH fl CI DISTANCE 7O NEAREST WELL _ft FOUNDATION ft PROPERTY LINE R `. Q DISPOSAL PONDS WIDTH �tL LENGTH_ ft DEPTH ft },� DISTANCETONEAREST WELL. ft FOUNDATION fl PROPERTY LINE n r ft IO. SEEPAGE PITS NUMBER _WIDTH a ft DEPTH !-7 ft DISTANCE TO NF.ARF.ST WELL ft RMINDATTON �� R PROPER"I7 LINE ��R I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANP THE WORK W ILL BE DONE 1N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. 1 CE NOTICE REQUIRED FOR INS ALL(209)453-7697 SIGNS R l VANTITLF. T t A. DATE wl LD (O i O Q o t � 1 u i G 't DEPARTMENT US'ONLY ENVIRON - TH DEPAR. ! Application Accepted By _ _I�'^--� Date_,-,5J(</v/may Areal-I 2- G�iee(Dk S_3 Glc, Final Inspection Date oT�}'i 77 ❑ SPECIAL PERMIT-Approved by' Character of Sol to De 13 Pit/Sump Soil Character: ' .� COMMENT........ ....... � _.—` } PE SC Received Chec Amount Date Invoice M 'P ermit Code INFO B Cash Renti[led .ervice Request 42-02-001 ONSRE WL 12/22/2003