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ONSITE WAEWATER TREATMENT SYrM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT v CALL(209)953-7697 FOR INSPECTIONS - EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS w CITY/ZIP <br /> CROSS STREET _ e /�/p�1/: ��a�� APN '— Q PARCEL SIZE■ d <br /> OWNERNAME r PHONE <br /> OWNER ADDRESS Q J L CITY/STATEIZIP � <br /> f CONTRACTOR l�i�.�/Y�l t PHONE <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP Z <br /> LICENSE C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# I <br /> TYPE OF WORK: Q NEW 1N�TALLATION REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE F <br /> ❑ REPLACEMENT ❑ DESTRUCTION IY <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NI7MBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ( h <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS V(T <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY. gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ftZ� I <br /> [i ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> xLEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES f•7 j ft <br /> DISTANCE TO NEAREST WELL S'D�� ft FOUNDATION ft PROPERTY LINE �� f� ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH R <br /> F DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> F ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> F ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL �J ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER J WIDTH l ft DEPTH ft <br /> DISTANCE TO NEAREST WELL - 6p ft FOUNDATION ` ,2 T ft PROPERTY LME J �7L ft <br /> rI HEREBY CERTIFY THAT 1 HAVE PREPARED THI5 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 Z4 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> a <br /> YM <br /> 01 U'T <br /> �y <br /> FF <br /> � F <br /> I <br /> i <br /> T <br /> 3 <br /> � � AR vvvv <br />