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d ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AvE -3--FL-STOCKTON CA 95202 - (209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7097 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS �� v tjA1--� K,/,e- /w CITy/zlp r1�L-T c CA c�- <br /> CROSS STREET CC_�N\`OH (A`r` APN 7-2 w- 0*7 0- Q (0 PARCEL SIZE L AGi"v. <br /> OWNER NAMEF f�~r GNr OZY-GGO h PHONE Q L3' 2,24 4 <br /> ice <br /> OWNERADDRESS . < i"e— CITY/STATE/ZIP MA-l1 t C.0 A C*.. 7 GGG <br /> CONTRACTOR PHONE .2 'iv 2Q" V <br /> CONTRACTOR ADDRESS <br /> CTI Y/STATE/ZIP <br /> LICENSE ❑CA2 ❑C-36 OTHER UMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: UK NEW INSTALLATION ❑ REPAIR/ADDFTION 0 ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: W�lESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> QV' <br /> NUMBER OF LIVING UNITS: p NUMBER OF BEDROOMS: 14 NUMBER OF EMPLOYEES: <br /> Q SEPTIC TANK TYPE/MFG( 4'L L j, ' tt CAPACITY gel #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL 2 J, ft FOUNDATION / ft PROPERTY LINE b O R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 9-.**'LEACH LINES O LEACHING CHAMBERS #OF LINES LENGTH OF LINES / ft <br /> DISTANCE TO NEAREST WELL 1'y tJ, ft FOUNDATION y ' ft PROPERTY LINE 3 r ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH fl LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> D SEEPAGE PITS NUMBER WIDTH III DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 H VCaQANCE NOTICE REQUIRED FOR INSPETIONS-PLEASE CALL(209)953-7697 <br /> SIGNED�r. .__ TITLE&N/ D� DATE �.�1,2 <br /> AM <br /> r <br /> IV <br /> Tj <br /> I , I� <br />