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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT''``/r1 /,e CALL 209 953-76/97 FOR INSPECTIONS EXPIRES 1 (Y]EAAR FROM DATE ISSUED <br /> JOB ADDRESS W W- K 1 /� CITY/ZIP � �/ %�73� T -yl <br /> �p m <br /> CROSS STREET kos; r-'� APN 2S - SC '2 PARCEL SIZE .2 rC L p <br /> O <br /> OWNER NAME S � /PHONE <br /> OWNER ADDRESS `LJ�U Loll, 1jL-( An" -L 1���E7 �L CITY/STATE/ZIP ✓Q Jd _ / <br /> �� 4-- C? <br /> CONTRACTOR PHONE ✓�`/) <br /> y <br /> 24 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP / <br /> LICENSE ❑C-42 ❑C-36 OTHER 0 NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: �� ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# -- 0-rCV 7SO LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ElREPAIR/ADDITION E3ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL OTHER s E <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> '5 2ec�U <br /> SEPTIC TANK TYPE/MFG CAPACITY — gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O <br /> ❑ LIFT STATION SIZE TYPE OF PLUMP El SAND OIL SEPARATOR(ENCLOSED SYSTEM) C• <br /> ❑ LEACH LINES * LEACHING CHAMBERS 69 436 #OF LINES�f C� LENGTH OF LINES /a v ft <br /> DISTANCE TO NEAREST WELL ,� ft FOUNDATION /".7 ft PROPERTY LINE t 0 R O <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft r^ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE _ ft �S <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft`FOUNDATION ft PROPERTY LINE ft f� <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MI IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 C <br /> SIGNED TITLE �,/If ✓ _ DATE <br /> —ja—:�LELVEID <br /> NO Q i <br /> v7T 4P RT E <br /> c <br /> y' - <br /> O <br />