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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE • STOCKTON CA95208-(209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Jos ADoREss REPLACEMENT 1-1CITY/ZIP s -I /_6g £_ /.y lis a- ; - i 22 1 f CROSS STREET y�:r- APPN~QJ ST.�P<+AL.R ff .�T�'Lo^J�� i�..d E- OWNER NAME �4-1- p/y/WK PHONE .2 0 Qa/C ^LS'� 7 /'975�� 1: OWNER ADDRESS -5 .2 / CITY/STATE/ZIP ' 94'790 7 -II cLIJ .s•� .�.?�!-�i7 CONTRACTOR VO J ff'�"/"e- PHONE 3m ^ 8 73 L! CONTRACTOR ADDRESS VK�7 D . s OX S I CITY/STATE/ZIP G.r! 4:0 - LA LICENSE //C42 C-36 OTHER NUMBER /JBB ald EXPIRATION DATE It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION it PROPERTY LME ft WATER TABLE DEPTH: I V - P 4J It GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # 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 24 HOUR A&AN6E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209).953-769; ' n SIGNED ' ' TITLE t�l.�/7I (- DATE h PE SIC Received ChecktW Amount Date Code INFO sh Remitted REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION ((� lis a- ; - i 22 1 f INSTALLATION WILL SERVE: RESIDENCE ... COMMERCIAL OTHER // NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: �/ C; SEPTICTANK TYPE/MFG %>/ �j CAPACITY /�mD 921 #OF COMPARTMENTS i1-. ❑ GREASE TRAP TYPE/MFG CAPACITY 921 # OF COMPARTMENTS DISTANCE TO NEAREST: WELL �y - IO ft FOUNDATION / J ft PROPERTY LINE ei R ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) L! It LEACH LINES ✓ LEACHING CHAMBERS 7r,4r # OF LINESu _ LENGTH OF LINES 7 �L, DISTANCE TO NEAREST WELL, O . ft FOUNDATION �" / ft PROPERTY LINE 7_7 It Z1 FILTER BED WIDTH ft LENG It DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION it PROPERTY LME ft ❑ MOUNDED WIDTH R LENGTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY Lft GT SUMPS WIDTH -4/ft LENGTH LIINE ~/ ft DEPTH O it DISTANCE TO NEAREST WELL & d ft FOUNDATION / ft PROPERTYLINE /.S % it ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH it DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH it DISTANCE TO NEAREST AEL- fl FOUNDATION ft PROPERTYLINE 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 24 HOUR A&AN6E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209).953-769; ' n SIGNED ' ' TITLE t�l.�/7I (- DATE h PE SIC Received ChecktW Amount Date Code INFO sh Remitted Permit! Service Reauset# CDy. Invoice # Permit ID# lis a- ; - i 22 1 f 42.01 Lfy , , 0;7-07 / ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/24112 A