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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-REFUNDABLEPERMIT CALL (209/) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 'e y l3 CITY/ZIP S Olb <br />CROSS STREET rfW 1 <br />OWNER NAME .!/ <br />OWNER ADDRESS •3 T- 7 e k <br />/� <br />L <br />CONTRACTOR O- l^ b N C O Al <br />CONTRACTOR ADDRESS n e- h <br />APNO" b / I / V / / PARCEL SIZE <br />PHONE <br />CITY/STATE/ZIP 11- O Cpom° t+ •3/ S . I <br />PHONE <br />a <br />m <br />a <br />v <br />0 <br />F <br />LICENSE ❑ C-42 <br />❑ C-36 OTHER A NUMBER EXPIRATION DATE <br />WATER TABLEDEPTH: <br />fl GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ <br />PERC TEST # <br />BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br />❑ REPLACEMENT ❑ DESTRUCTION <br />INSTALLATION WILL <br />SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />M <br />uL <br />SEPTIC TANK <br />I <br />TYPE/MFG ,1 c' CAPACITY AD U gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />_ <br />TYPE/MFG CAPACITY. gal # OF COMPARTMENTS <br />❑ <br />PKG TX PLANT <br />_ <br />DISTANCE TO NEAREST: WELL /lJ O R FOUNDATION ft PROPERTY LINE ISD + ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />�y n <br />EI LEACHING LEACHING CHAMBERS cv, 36 OF LINES LENGTH OF LINES 1-52 70 <br />W <br />_ .2 _R <br />DISTANCE TO NEAREST WELL / D D ft FOUNDATION L O Ci R PROPERTY LINE,3 (7 ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH R DEPTH <br />_11 <br />DISTANCE'TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE R <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />❑ <br />SUMPS <br />_ft <br />WIDTH ft LENGTH fl DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH fl DEPTH Ij <br />DISTANCE To NEAREST WELL fl FOUNDATION ft PROPERTY LINE R <br />❑ <br />SEEPAGE PITS <br />NUMBER (4' WIDTH 7 R DEPTH 2(S ft <br />r <br />DISTANCE TO NEAREST WELL I 5—ck R FOUNDATION ) d R PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I 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 />MINIMUM 2 HOUR�D ENO CE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9/53-7697 <br />SIGNED <br />—7 <br />Y <br />TITLE -.4 11 4e -L DATE -' 7 - 6 6 <br />