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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E HAZELTON AVENUE-STOCKTON CA 95205.(209(068-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 9 7697 FOR INSPEC710N5 / E PIRES 1 Y F OMD E ISSUED <br /> JOB ADDRESS 21TJ 04ja4ca Cm21P L—SII <br /> _ J { <br /> CROSS STREET /' APN IO ; IoO_x PARCELSIZE <br /> /J 0 <br /> OWNER NAME PHONE <br /> OWNER ADDRESS J/� CITY/STATEMPP / <br /> CONTRACTOR LPG M ;S /� JZI/Y1 J4 / ja�L' PHONE Q 1-,) <br /> CONTRACTOR ADDRESS F7/LLJII Ph /} /� /CITY/STATEMP <br /> LICENSE iii' C-42 11C-36 OTHER NUMBER tJ>r 0 /O-�EE NAvoN DATE <br /> WATFA TABLE DEPTH: It GEOGRAPHICAL INFORMATION: COONINtes X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEWINSTALLATI Y REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WI LL$ERNE: L RESIDENCE II COMMERCIAL V OTTER <br /> NUMBEp OF LIVING UNITS: ]NUMBER OF BEDROOMS: NUMBER <br /> /j�y NUMBER OF EMPLOYEES: /J <br /> r SEPTIC TANK TYPERMFG Z. CAPACITY /A f�l� gal #OFCDMPARTMENTS z_ <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> DISTANCE TO NEAREST: WELLSh!� It FOUNDATION_�-71 It PROPERTY LINE+S fl <br /> ❑ LIFTSTATION SIZE TYPE OF PUMP O PKG TK PLANT Cl SAND OIL SEPARATOR(ENCLOSED SYSTEM( <br /> LEACH LINES LEACHING CHAMBERS_ #OF LINES-.2— LENGTH OF LINES 3111P fl <br /> DISTANCE TO NE/.REST VIELL_-( L!20 - R FOUNDATION�f TJ ISL It PpOPERTYLINE It <br /> ❑ FILTER BED Mow ft LENGTH It DEPTf ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE it <br /> ❑ MOUNDED Wow It LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE it <br /> ❑ SUMPS Wow It LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL R FOUNDATION fl PROPERTY LINE it <br /> ❑ DISPOSAL PONDS Mow It LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL fl FOUSIDATON ft PROPERTYUNE fl <br /> SEEPAGEPITS NUMBER /I Now- _ 3 Jam% DE"�S� ft <br /> DISTANCE TO NEAREST WELL S' <br /> p ft FOUNDATION fIJ �" ft PROPERTY LINE 2 fl <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINI 26 HOU DIZCE NO ERE U/RED FOR INSPECTIONS-PLEASE CALL 209 95.G3-7697 _ <br /> SIGNED TITLE t✓ L !/ pATE�L/a1�S <br /> s <br /> Ali I <br /> ru <br /> T <br /> t- <br /> EPARTMENi USE N /. <br /> Application Accepted - Data 'D�,/Z Area O 4 Employee ID# �-9✓✓� <br /> Firwl lnspac0on Data &G&eJ/Z I. SPECIAL PERMIT-Approved by <br /> Character aT$ollto pth ol3 Ft: Pit/Sump Son Character: <br /> COMMENTS_ LNM++ <br /> PE SC Reoeivad Checll#/ AmountDataPetmN Invoice Permit 1p# <br /> Code INFO B Cash Rerllmad- SanNes uwta <br /> JAI It I (ice i lad Lalzb 1 15A10M <br /> I2-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4FH/13 <br />