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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />ii�" <br />SAN JOAQUIN COUNTY ENWRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET • STOCKTON CA 95 2 - (209) 46"20 <br />NON-REFUNDABLE PERMIT L:AlLL (1091 933-IbVI FOR INSPECTIONS G](PIKkb I f tAK FKVM L#AI t Ibbut <br />Jos ADDRESS �D 0 _ e; �) CIITyYIZZIIP L_�P"7Z �SL- <br />CROSSSTREET /� ��y- � - , ISD-•[ C APN r�J I' ^KJ PARCEL SIZE <br />OWNERNAME `; �,=pp�''^! %e r 4�L� �P HH,OONEE, VLQ- --V) F) Z. <br />OWNER ADDRESS ''9094 6. _ , „ `� � CITYISTATEIZIP pL44M �7� L5L�o <br />CONTRACTOR :1- �- A:D Z1�1c. PHONE 3611-"Z.5S 4_ <br />CONTRACTOR ADDREss Zo It S. kyia l0 9-}},� C(TYISTATVZ[P <br />LICENSE MC -42 11C-36 OTHER NUMBER 77R 48 EXPIRATION DATE !O9 <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # <br />9UILDING PERMIT# <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION 'f>L <br />REPAIRJADOmON <br />❑ ENGINEER DESIGNED 1ALTERNATNE <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />n REPLACEMENT <br />❑ <br />DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />COMMERCIAL <br />❑ OTHER <br />NUMBER OF LNIN6 UNIT$: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />SUMPS WIDTH ft LENGTH R <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />0 $EPTICTANK <br />TYPEIMFG G L�Z <br />CAPACi7Y <br />gal #OFCOMPARTMENTS <br />O GREASE TRAP <br />TYPEIMFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />-ft r� <br />SEEPAGE PITS NumurR Com— WIDTH .Ifc7 u <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />0 LIFT STATION <br />SIZE TYPE OF PUMP <br />LI PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />0 <br />LEACH LINES ❑ LEACHING CHAMBER$ # OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTYLINE R <br />0 <br />FILTER BED WIDTH ft LENGTH R <br />DEPTH It <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />R PROPERTY LINE ft <br />0 <br />MOUNDED WIDTH R LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />f1 PROPERTY LINE ft <br />0 <br />SUMPS WIDTH ft LENGTH R <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />R PROPERTY LINE R <br />• <br />DISPOSALPONDS WIDTH k LENGTH R <br />DEPTH tt <br />DISTANCE TO NEAREST WELL FOUNDATION <br />ft PROPERTY LINE R <br />-ft r� <br />SEEPAGE PITS NumurR Com— WIDTH .Ifc7 u <br />ft DEPTH 7!S-' ft <br />��y,, 7 <br />DISTANCE TO NEAREST ELL mmt3. t FOUNOAT10N 6 y n + <br />W <br />R PROPERTY LINE Mt 'F ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS • PLEASE CALL (2 09) 953-7697 <br />10I 1-410S <br />SIGNED <br />TITLE <br />DATE <br />