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ONSITE WASTEWATER TREATMENT SYS MM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3""FL-STOCKTON CA 95202 - (209)468-3320 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS /EXPAIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7 //�S Sy4 CITY/ZIP <br /> [�/V� > <br /> CROSS STREET � L m <br /> _ APN DSJ -0 /O 0 �J PARCEL SIZE ( Q D <br /> y. _ ` fns(� (� _ y o <br /> OWNER NAME 0 1 Gam- -S 1-ral')K NI C 3G 2.i +5 PHONE <br /> OWNER ADDRESS C- / CITY/STATE/ZIP � � /J <br /> CONTRACTOR `� �1-A 7y X-��7 <br /> 1 <br /> PHONE .i[.%!J ✓ Tom' (;,j,CONTRACTOR ADDRESS-4 l� �'U! , <br /> CIT <br /> (Y <br /> �/STATE/ZIP C.1- <br /> LICENSE x-42 LI7 C-36 OTHER NUMBER q4 d z �,' �� U C� <br /> EXPIRATION DATE <br /> WATER TABLE DEPTH: co 1 "r- ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NuNUM13ER LAND USE APPLICATION# l" <br /> TYPE OF WORK: LJ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE. ❑ COMMERCIAL OTHER E'-'S+ p.,,- .✓ <br /> NUMBER OF LIVING UNITS: /Y C14-f— <br /> OF BEDROOMS: i NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG C41rA- �C14-.� CAPACITY \Z� V gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> � r � <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION (7/�v ft PROPERTY LINE�oV tl <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ElLEACHING CHAMBERS #OF LINES LENGTH OF LINES c/0 ft <br /> DISTANCE TO NEAREST WELL-3/0/ fl FOUNDATION �� ft PROPERTY LINE J� V , ft <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft C <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH_ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ftSEEPAGE PITS WIDTH ft LENGTH ft DEPTH �-� j ft <br /> DISTANCE TO NEAREST WELL 35 o It FOUNDATION �D II PROPERTY LINE 11190 ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE L AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MI 1 UM O ADVA 1QCTICE REQUIRED FOR INSPE TIONS-PLEASE CALL(209)953-7697 C� q <br /> SIGNED i TITLE DATE. <br /> � ff <br /> S <br /> 3 f <br /> P/L <br /> z <br />