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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT .?r!1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 3114 E WEBER AVE-3"'FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS CITY/ZIP <br /> CROSS STREET i <br /> AP C PARCEL SIZE <br /> OWNER NAME �`/ '�"'� PHONE, En <br /> OWNER ADDRESS CITYISTATEIZIP <br /> CONTRACTOR �a�//'1 ti�PP 1 L - �` J-�e� _ PHONE I <br /> CONTRACTOR ADDRESS 7 -1 I'lJI IJ I CITYISTATF/TdP <br /> LICENSE ❑C-42 0 C-36 OTHER NUMBER ._ EXPIRATION DATE <br /> WATER TABLE DEPTH: A GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION Ik <br /> TYPE OF WORK: ❑ NEW INSTALLATION F REPAIRIADDITION ❑ ENCINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION (' <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER { n <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: V <br /> J SEPTIC TANK TYPEIMFGCAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG!!!�� <br /> CAPACITY gal N OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION fl PROPERTY LINE fl <br /> ❑ LIFT STATION SIZE TYPE OF PUMP4 ( ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 11LEACH LINES 19 LEACHING CHAMBERS y !� C 2`-� A OF LINFS LENGTH OF LINES c7'Sy ft ` <br /> DISTANCE TO NEAREST WELL R FOUNDATSON A PROPERTY LINE R <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDA710N ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL A FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH_ fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> m SEEPAGE PITS WIDTH � R LENGTH R DEPTH <br /> fl <br /> DISTANCETO NEAREST WELL I FOUNDATION .$ A PROPERTY LINE fl <br /> EREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> . r�- 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 ��Gh IIV r DATE a <br /> /ml I <br /> �o <br /> 0 <br /> d <br /> N <br /> SA A <br /> PEN <br /> �AFL <br />