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I l Ulp l L' 1V1 1 x 1\ltll 1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D' lTMENT 304E WEBER A` 3°'FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT NIVALL(209)953-7697 FOR INSPECTIONS 1,w*XPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS D Si C� ,+ �•. CITTV/ZIP �S ti <br /> CROSSSTREET �IC.�GJ/L.P (� APN [�j —O� y� > <br /> PARCEL SIZE rte-_ o <br /> OWNERNAMEI� ^ �p ^� <br /> /�aN. J�i PHONE <br /> OWNER ADDRESS L CITYISTATE/ZIP <br /> CONTRACTOR D z- (J'7(,i ,p,� ,p PHONE <br /> CONTRACTOR ADDRESS �� /��O 1/[/ / �{�'/CITY/STATE <br /> E/ZIP �5pV <br /> LICENSE 2 ❑C-36 OTHER NUMBER 4ey��S EXPIRATION DATE <br /> WATER TABLE DEPTH: /1719 ft GEOGRAPHICAL INFORMATION: Coordinates X Y V <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> r TYPE OF WORK: ❑ NEWINSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: ♦ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES- <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS =" <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS iil�Y11` <br /> s. ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) Q� <br /> / i� <br /> n. ❑ LEACH LINES LEACHING CHAMBERS S-L6h/ TS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION_�R PROPERTY LINE <br /> R <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> a. DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH fl <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE <br /> 2fl <br /> SEEPAGE PITS WIDTH i ft LENGTH R DEPTH 2-51 ft <br /> DISTANCE TO NEAREST WELL ft FOl1NDATION �R PROPERTY LINE ft <br /> r 1 HEREBY CER AT i HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE L S AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINI UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ! TITLE DATE 7-e-3 <br /> i <br /> n �v <br /> lG <br /> r <br /> n <br />