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ONSITE WAw,4'EWATER TREATMENT SY,,..,EM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"O FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS • EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 2--7'YL4D t>0yJI-.eeD CITY/ZIP <br /> CROSS STREET La t3tT� �D, APN �1 2 < - Io <br /> PARCEL SIZE J <br /> OWNER NAMED p <br /> PHONE <br /> y <br /> � y <br /> OWNER ADDRESS CITY/STATE/ZIP 2 pC <br /> CONTRACTOR - ok� -Oor t`C. -D"�--/ I�--L ��C, PHONE ,�Ip `�Ti�✓Z <br /> CONTRACTOR ADDRESS t5 t IJ CITY/STATE/ZIP ZO'7 <br /> LICENSE WC-42 ❑C-36 OTHER NUMBER -7��R EXPIRATION DATE a 7-/f--.C3 6 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> — ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: /7��� I NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> + ❑ SEPTIC TANK TYPE/MFG-?ffC C:/TGf-Z-",�Ojf CAPACITY In) gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ('moo t r ft FOUNDATION 3O' ft PROPERTY LINE /_ <br /> `7 ' ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ILL. LEACH LINES ❑ LEACHING CHAMBERS #of LINES� LENGTH OF LINES L-110 ft <br /> DISTANCE TO NEAREST WELL loo r+ ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH tt DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R �� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER WIDTH G�r� �( ft DEPTH �� ft G <br /> DISTANCE TO NEAREST WELL I ,>c� t t-t FOUNDATION (0D ft PROPERTY LINE �Z.� I ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE 071 l6(0`f <br /> S O Q IN O N FY <br /> d <br /> 0 0 <br /> y ! cl i-9 <br />