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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT / CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 777 /J! -'Li. S�_ .�7c�� Cln(ZIP %�Gl�ft9,rb <br />CROSS STREET �7 �/ /'GJf�, �� �%)'Z APN a/7— "/ O ✓y PARCEL SIZE a�r� <br />OWNER NAME_ NI f-rA , _ill S1/V PHONE W � - 77y- c 35 7 <br />OWNER ADDRESS CITYISTATEMP <br />CONTRACTOR Ceri�iZ/:L '! 'Oh c_ PHONE i "<'G a.?� <br />CONTRACTOR ADDRESS _ j %yli .`?�u,?iTct�C, 7i/'i� (/,i/c. CITY/STATFIZIP <br />LICENSE ❑V-42 ❑GC -36 OTHER NUMBER 7 SGyYS EXPIRATION DATE IU,�Zl <br />WATER TABLE DEPTH; I V <br />❑ PERC TEST # <br />_ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />BUILDING PERMIT # LAND USE APPLICATION # <br />DN REPAIRIADDITION _ ENGfNEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM - DESTRUCTION <br />INSTALLATION WILL SERVE: 4�- RESIDENCE ❑ COMMERCIAL fl OTHER <br />LEACH LINES <br />-1 LEACHING CHAMBERS <br />NUMBER OF LIVING UNITS: I <br />NUMBER OF BEDROOMS: V <br />NUMBER OF EMPLOYEES: <br />DISTANCE TO NEAREST <br />WELL % SG , <br />ft FOUNDATION /vi:' <br />ft PROPERTY LINE %O ft <br />❑ FILTER BED <br />❑ <br />SEPTIC TANK TYPEIMFG 1r a:- <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />DISTANCE TO NEAREST. WELL <br />R FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />-1 LEACHING CHAMBERS <br />#OF LINES �_ <br />LENGTH OF LINES q6 ft <br />DISTANCE TO NEAREST <br />WELL % SG , <br />ft FOUNDATION /vi:' <br />ft PROPERTY LINE %O ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />It <br />DEPTH ft <br />DISTANCE TO NEARESTELL <br />W <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />It <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE It <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE ft <br />Gg-- SEEPAGE PITS <br />NUMBER 1'4 WIDTH <br />3 ft <br />DEPTH sS ft <br />DISTANCE TO NEAREST <br />WELLS� <br />It FOUNDATION 1 <br />ft PROPERTY LINE ZlI ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4;14:16 <br />n <br />Y <br />A <br />