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❑ SEPTIC TANK TYPE/h1F CAPACITY bCC:Lgai # OF COIrIPARTMENTS ❑ GREASE TRAP TYPEIMFG _ - _._._ CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL__ ft FOUNDATION _ ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION_ ft PROPERTY LINE ft ❑ FILTER BED WIDTH _ ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SUMPS WIDTH ft L G % / ft DEPTH L Lit ft DISTANCE TO NEAREST WELL =ft FOUNDATION_ ¢ ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTHft DEP{' 1 wEiN-T ft 1 DISTANCE TO NEAREST WELL ft FOUNDATION ft tRtl' LIN ft ❑ SEEPAGE PITS NUMBER WIDTH R DE ft ft DISTANCE TO NEAREST HELL ft FOUNDATION ft �ROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN. COUNTY ORDINANCES, (� STATE LAWS LAWS AND RULES AND REGULATIONS OF SAN,JOAQUIN COUNTY. OUNTY. vlNJ4 FORMS 209)953-7697 L-2-4-9 SIGNS TITLE DATE Ojly`'l , a COMMENTS 0`�Ic46c/-if - -if=?-1st i �f'Ec_< Imo_ 124-` ce oif - Alo Apc••-fz -2- 42-01 L 42-01 ` l il'wfJ� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 1014107 f ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNT' ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 NON-REFDN IT.. , ` , A(209,"53-761 FO ECTIONS EXP( 1 Y M E ISSUED JOB ADDRESS Vl jb • "fzIP ' 1 y l 1 r 1^, j/� (i L � ,!�{ CROSS STREET '` C �� T 1 -t APN I^ \ '�- P CEL 12E 'i p 10 - PHONE OWNER NAME � CITYISTATE/ZIP � •` 4 OWNER ADDRESS- ^/ `t �{--y{ tL �O�" PHONE \ '• CONTRACTOR L^� ,! / p - % �� •� CITYISTATE(ZIPI - `J• CONTRACTOR ADDRESS LICENSE YC -42 1,7l j1 OTHER —A _ NUMBERC65[l_EXPIRATIONDATE D WATER TABLE DEPTH: h GEOGRAPHICAL INFORMATION: Coordinates X PERC TEST # RMIT # LAND USE APPLICATION BUILDING PE # TYPE OF WORK: NEW INSTALLATION REPAIRlAOOITION ENGINEER DESIGNED (ALTERNATIVE REPLACEMENT DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER NIIYRFR DF LIVING UNITS: NUMSER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/h1F CAPACITY bCC:Lgai # OF COIrIPARTMENTS ❑ GREASE TRAP TYPEIMFG _ - _._._ CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL__ ft FOUNDATION _ ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION_ ft PROPERTY LINE ft ❑ FILTER BED WIDTH _ ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SUMPS WIDTH ft L G % / ft DEPTH L Lit ft DISTANCE TO NEAREST WELL =ft FOUNDATION_ ¢ ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTHft DEP{' 1 wEiN-T ft 1 DISTANCE TO NEAREST WELL ft FOUNDATION ft tRtl' LIN ft ❑ SEEPAGE PITS NUMBER WIDTH R DE ft ft DISTANCE TO NEAREST HELL ft FOUNDATION ft �ROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN. COUNTY ORDINANCES, (� STATE LAWS LAWS AND RULES AND REGULATIONS OF SAN,JOAQUIN COUNTY. OUNTY. vlNJ4 FORMS 209)953-7697 L-2-4-9 SIGNS TITLE DATE Ojly`'l , a COMMENTS 0`�Ic46c/-if - -if=?-1st i �f'Ec_< Imo_ 124-` ce oif - Alo Apc••-fz -2- 42-01 L 42-01 ` l il'wfJ� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 1014107