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SCANm <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> -TION-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> !! ADl <br /> `OB DRESS L CITYIZIP <br /> CROSk STREET APNa <br /> r PARCEL SIZE o <br /> .)WNER NAM£ X <br /> / E G <br /> 1 < �7 Q 9 �~�3_ :1 <br /> OWNER ADDRESS rZA g 7"T0 / IJ <br /> y CITYlSTATE/ZIP 46SPA <br /> �:ONTIRAGTOA PHONE — <br /> F <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br />� p <br /> ECENSE 0 C-42 ❑C.36 -_ OTHER NUMBER E%PiRATION DATE c� <br /> _NATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> + _FYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIAD61TION0 ENGINEER DESIGNED/ALTERNATIVE <br /> j ❑ REPLACEMENT ESTRUCI'IO <br /> ^INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCI L ❑ OTHER <br /> r1 j NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: (tel <br /> 1LL 1•i� <br /> Imo❑ SEPTIC TANK TYPEIMFG CAPACITY gal 4 OF COMPARTMENTS <br /> ❑ ,CREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> F U <br /> IPKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED <br /> � SYSTEM) � <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH fl DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft �❑ . MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> [ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> �{❑ SUMPS WIDTH ft LENGTH ft DEPTH fl <br /> I DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> w❑ DISPOSAL PONDS WIDTH fl LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> F' <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY L[NE ft 1 <br /> Ell <br /> kEI HEREBY CERTIFY THAT 1 HAVE PREPAREDTHIS APPLICATION ANDTHE WORK WILLB£DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTYORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> i <br /> 41iNIMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CAL],(769)953-7697 <br /> 1CNED :221TITLEX6:fte�zy DATE <br /> R .I <br /> i _ <br /> Fit I <br /> ±I <br /> I <br />