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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 C py CITY21P SfYJl) 4r'a"Ja <br /> CROSS STREET I /�j- 2l _ /CjcC APN 'U gel VId.5 PARCEL SIZE & <br /> OWNERNAME V&-O3->(", e, SYJr1u�17L]Afl,// �:/ 1 PHONE 1p/Ja 316 <br /> OWNER ADDRESS ct A,f O it Lf SL"" V4-t- - It,` JJ CIITYISTATE21P SI VL of Z'` ID <br /> ' CONTRACTOR �_ �.mhso� e4+!YV ATONE <br /> CONTRACTOR ADDRESS .9 1I1-' LYSOwy,- CITYISTATE0P <br /> LICENSE [J, .12 Ll'IC-36 OTHER NUMBER V O VSMXPIRATION DATE <br /> WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> II PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION 04, REPAIRIADDITION ENGINEER DESIGNED IALTERNA14VE � <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: A -RESIDENCE ❑ COMMERCIAL LI OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: Z 7E NUMBER OF EMPLOYEES: <br /> pL SEPTIC TANK TYPEIMFG CAPACITY L CAPACITY Jlle� gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL 7Q2 t ft FOUNDATION /O ft PROPERTY LINE �Or' ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> CIL LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL ZOO ft FOUNDATION—,PO it PROPERTY LINE �Q� R <br /> ❑ FILTER BED WIDTH ft LENGTH - ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ SUMPS WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION it PROPERTY LINE ft <br /> ' ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Uf-- SEEPAGE PITS NUMBER I WIDTH 3' It DEPTH a:E' it <br /> DISTANCE TO NEAREST WELL g;W r- ft FOUNDATION �� ft PROPERTY LINE ��� it <br /> I HEREBY CERTIFY THAT 1 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 /> MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> i <br /> I I <br /> v <br /> 770 <br /> n <br /> O 7 QF <br /> U2 <br /> ' a a2 <br /> v OC <br /> O¢ <br /> ' <br /> LL <br /> 2 <br />