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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 98202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS v V N Crrylzp <br />{f� APN 2g Us QC Z PARCEL SIZE <br />� <br />CROSS STREET <br />OWNER NAME l ) -7 � PHONE C( <br />OWNER ADDRESS I k ' - C - ppa'nJ A-)(— /ZI <br />CITY/STATEP SA L)�J sk, GA I 'T S) -2 <br />,P �,.[n PHONE c''��?+ <br />CONTRACTOR � � d D� !AI/ � �� �- _� � _ <br />CONTRACTOR ADDRESS i • ce �V ✓� �'� v — CITYISTATE/ZIP 11-7,.1 _ I G. A '1 1i S J^ <br />-i <br />LICENSE QC -42 IJC-36 OTHER A NUMBER � r _EXPIRATION DATE � 7 <br />WATER TABLE DEPTH: <br />�V R GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # -] BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: <br />lI ENGINEER DESIGNED 'ERNATIVE <br />, <br />❑ NEW INSTALLATION ❑ REPAIRIADDITION - I f <br />E7 REPLACEMENT U OUT -OF -SERVICE SEPTIC SYSTEM fii, DESTRUCTION Sa.,l <br />INSTALLATION WILL SERVE: If RESIDENCE ❑ COMMER L ❑ OTHER <br />NUMBER OF LPANG UNITS: I NUMBER OF BEDROOMS: Z.. NUMBER OF EMPLOYEES: <br />0 SEPTIC TANK TYPEJMFG L �U L'c�[fc CAPACI / -2-0 gal #OFCOMPARTMENTS <br />❑ GREASETRAP TYPEIMFG CAPACITY gal #OFCOMPARTMENTS <br />DISTANCE TO NEAREST: WELL CI ' it FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPEOFPUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />Ll <br />LEACHLINES <br />f] LEACHING CHAMBERS <br /># OF LINES <br />LENG AFI OF 5 <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNOATI N <br />R P PERTYiLINE <br />' ft <br />O <br />FILTER BED <br />WIDTH 3 l ft LENGTH <br />- <br />DEPTH h <br />DISTANCE TO NEAREST WELL 6 ft FOUNDATION ft PROPERTRLILIE <br />❑ <br />MOUNDED <br />WIDTH R LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS <br />WIDTH R LENGTH <br />R <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />R PROPERTY LINE <br />ft <br />'] <br />DISPOSAL PONDS WIDTH ft LENGTH <br />R <br />DEPTH <br />It <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />R PROPERTY LINE <br />ft <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED SLAWS <br />AAVIRULES AN <br />DE <br />D REGULATIONS OF SAN N ALCOR ANCE WITH <br />SAN JOAQUIN COUNTY ORDINANCES. <br />STATE <br />ml—m— t..v.....-.-- ----- l- <br />clrum TITLE �v ti 7' 4 �YJ/ DATE qZ3 J / <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />42-01 <br />W21110 <br />