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tl,�Nn ONSITE WASTEWATER TREATMENT SYSTEM PERMIT ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)466.3420 14ON-REFUNDABLE PERMIT CALL(209)953-7657 FOR INSPECTIONS EXPIRES 1 YEAR FR M DATE ISSUED JDs ADDRPJ3s Crt,mPP m CROSS STREET JZ 1�1L�'4. APIN P'AR`CEL S¢E J4� y3 OWNER NAME, �.+FA.Y"� '=� Y U J �G PHONE_ -T (�� •��. / OWNER ADDRESS to £- O A G- Cm/STATEIZIP CONTRACTOR PHONE i CONTRACTOR ADDRE35 (It3 ( �•�-•��v\12-1,—!17 Ca—^ `^ _CR1<f� U Y/$TATFIZJP c'(�_f SSS S�j LICENSE `OC42 IJC-36 OTHER C-Z-t NUMBER P-"I It k- Y EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 13 PERC TEST # I I BUILDING PERMIT# LAND usE APPLICATION# 1�1 TYPE OF WORK: L: NEW INSTALLATION REPAIWADDITKIN - ENGINEER DESIGNED/ALTERNATIVE -1 REPLACEMENT - DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE G COMMERCIAL C OTHER �y ! NUAI9ER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: 1 T{ ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS 111 I, O GREASE TRAP TYPEIMFG CAPACITY gal #or COMPARTMENTS DISTANCE TO NEAREST: WELL it FOUNDATION _ ft PROPERTY LINE R Q LIFT STATI ON SIZE TYPE OF PUMP O PKG TX PLANT 0 SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACHLINES ; LEACHING CHAMBERS #OFL(NES LENGTHOFLINEs It DISTANCE TO NEAREST WELL ft FOUNDATION_ ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION_ ft PROPERTY LINE ft Q MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL_it FOUNDATION ft PROPERTY LINE ft Q SUMPS WIDTH ft LENGTH_ ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ O(SPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOU/IDATION ft PROPERTY LINE it ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It DISTANCE TO NEAREST WELL ft YOUNDATION it 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_ MINIMUM 24X ADVANCE NOTICEREQU ED FOR INSPECTIONS-PLEASE CALL(209)953-MY SIGNED TITLEDATE 2 S A C '• I�r DEPARTMENT E 014LY Application Accepted Date Area Employee iD# � _TT Final Inspection B - a Date ❑ SPECIAL PERMIT-Approved by Character of So11 to De of 3 Ft. PittSump Sall Character: COMMENTSJLLl2L I?T- ry/ iui-'ll,�/Yi� -C!G^X/-tct:.Lc'.?�T4/�Zf'I /�✓.�!�.4L7J'f'�a�cl�l-l�L`sCij_ .Qi�•2'��/.rs� ��_'. PE Sc Received a Amount Date Invoice# Permit IDD Dde INFO Cash Remitted ServICCR st# S ` 5 0 5 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT