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ONSITE WASTEWATER TREATMENT S}.'STEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE -3-FL- STOCKTON CA 95202 - (209) 468-3420 IN IIIc -REFUNDABLE PERMIT CALL ILUY) 953-7697 FOR INSPECTIONS 1 YEAR FROM DATE ISSUED JOB ADDRESS C' � •� . pfJ`(�J1/�VI A 4 H. ( �E JX�P-I (RHES CITY/ZIP L -V &41sy/jI 95j 3-+ CROSS STREET -la 16Y i`•�P r L In 1�-a APN OSI ' 3�D ��,Q ❑ NEN' INSTALLATION 2 /L PARCEL SIZE • �7TT/� . OWNER NAME _ 4AA'gs6y� T I R-(., ❑ REPLACEMENT ❑ DESTRUCTION OWNER ADDRESS �7 q i�•(V F I � r CITYISTATFJZIP TPIfO (NE YejLCi4 �/ 1 / T/+�1� �5 J5 L( CONTRACTOR 1y .PA6� o • fi'VI�/X /�S-/LE-7764 /� ys66-,n P u6c-• TYPE/MFG CAPACITY (O 7 -d3 �"O ) CONTRACTOR ADDRESS `f OZ ftp- L„ ow -c f'i'a [/VLcAA CITY/STATE/ZIP 1PHONE L,Lgk , c4lk J SZ4(-) LICENSE ❑ C42 Ll C-36 OTHER NUMBER EXPIRATION DATE ❑ LEACH LINES D LEACHING CHAMBERS # OF LINES I[ liEOGRAPHICALINFORMATIONI C00PQID91C5 x I' Ed FERC TEST (S) NUMBER 1 LAND USE APPLICATION # c - S -c) TYPE OF WORK: ❑ NEN' INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OP COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP D SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES D LEACHING CHAMBERS # OF LINES LENGTH OF LINES R DISTANCE TO NEAREST WELL ft FOUNDATION ❑ FILTER BED WIDTH R LENGTH DISTANCETO NEAREST WELL ft FOUNDATION ❑ MOUNDED WIDTH R LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SUMPS WIDTH fl LENGTH DISTANCE TO NEA REST WELL ft FOUNDATION ❑ DISPOSAL PONDS WIDTH R LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SEEPAGE PITS WIDTH R LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R ft DEPTH R ft PROPERTY LINE Ij R DEPTH ft R PROPERTY LINE ft ft DEPTH ft R PROPERTY LINE ft R DEPTH ft ft PROPERTY LINE fl R DEPTH I{ ft PROPERTY LINE It I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWSAND RULES AND REGULATIONS OP SAN JOAQUIN COUNTY. SIGNED /:ZL MINIMUM SPECTIONS- C' ADVANCE pn b2A t 7R� 1 TLE NYom[ TIT&1 VI t�Y PLEASE CALL n— }aL� ,kPtL 9)n9_53-7697 Q'� 4I-01-001 12202 ONSITE WASTEWATER PERMIT