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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNT'ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3-FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMITCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS / A-1 CITY/ZIP-5 V S---) r-- H CROSS STREET `4I1Q e?I(C I WIV APN L�C-)700 42S PARCELSIZE 9• O OWNER NAME lL dl ` PHONE ae9 p l- !;I-213y/3 OWNER ADDRESS T1aXJ, I(J r2Q CITV/STATF1ZIPp t267'SA.L��71T CONTRACTOR PHONF:a'C?'c)_f�� I a-3 CONTRACTOR ADDRESS 2 CITY/STATE/ZIP -1-Al I LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: CoordlMtef X Y ❑ PERC TEST 0 BUILDING PERMIT N LAND USE APPLICATION N TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER 1't NUMBER OF LIVING UNITS: n 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTICTANK TYPE/MFG !"P !'` CAPACITY gal NOFCOMPARIMEYFS ❑ GREASE TRAP TYPE/MFG _ CAPACITY gal #OF COMPARTMENTS ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION R PROPERTY LINE li ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES A DISTANCE.TO NEAREST WELL ft FOUNDATION R PROPERTYLINE R ❑ FILTER BED WIDTH_ R LENGTH ft DEPTH R DISTANCE TO NEAREST WELL R FOUNDATION R PROPF.RTYI.INE R ❑ MOUNDED WIDTH ft LENGTH ft DEPTH R DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH _R LENGTH ft DEPTH R DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH R DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft $1 SEEPAGE PITS NUMBER O WIDTH�1 t rR DEPTH Z R DISTANCE TO NEAREST WELL T R FOUNDATION ^Jd R PROPERTY LINE 300' R 1 HE BY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND'I HE T1 ORK N II.L BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. .'IM 24 HOUR ADVANCE:NOTICE REQUIRED FOR INS F.A1�IIO.lNtS-PL ASF.CALL(209)953-7697 �s SIGNEDN- TITLE Sv! DATE p 4 � rr1 Iy v \, \ 'JI 1 G w / N "\c Fi ' H D G .. ( DEPARTMENT 5 — —--- '— - --- _ _�� Application Accepted t3Ft- PE Date Area Employ=IDN Final Inspection By Date ! /. (,�,•> SPECIAL PERMIT-Approved by Character of Soil to De PIU ump Soil Character. COMMENTS _ At Z _ SC Received CkeekN/ Amouat Date Permit/ Invoice# Permit IDM Code INFO B Cash Remitted Service Request IT 104-15, .Z 42-02-00I /v--dL ILL 'G�l J�j /�E:3"l'2CI[%'7• "Y-!�/ Jd� (JL"' ,.S• -y°� SI EWASTE/SVATERSI.RMIT 12/22(2003 �/iikG S•7.&r,0 --4"W-riW C-Au Z.� wL'.Rc�=!/iB7fu+2 6,1.co Z;)J3Is