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VI <br /> ONSITE WASE WATER TREATMENT SYST M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Db✓ARTMENT <br /> 304 E W EBER A.., -3'0 FL-STOCKTOn CA 95202 - (209)468-3420 <br /> NON-REFUNDABL PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS M GpE O <br /> CITY/ZIP L <br /> H <br /> CROSS STREETSNT'1 APN O19 � 3f��CM ZI• ACI-' y <br /> ( <br /> �O&A GASSn1E� PRceLSlze,U� o <br /> OWNER NAME <br /> U 3J K 3 Z PHONE y <br /> OWNER ADDRESS CITV/STATE/ZIP �� <br /> CONTRACTOR 11"w� MPrPµ✓ Pxone 709 374 -6(013, <br /> y� I <br /> CONTRACTOR ADDRESS V • �JX ( w CITY/STATE/ZIP `G pr CA <br /> LICENS LIC-42 L2 C-36 OTHER NUMBER EXPIRATION DATE <br /> W ER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: C00Tdln9tes X y <br /> PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAI R/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> I INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL III FOUNDATION ft PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> V <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH ft C* <br /> DISTANCETONEAREST WELL R FOUNDATION ft PROPERTY LINE ft C <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft Try <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH, ft U <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R 7 <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH Ij <br /> DISTANCE TO NEAREST WELL ft FOLINDATION PROPERTY LINE ft ` <br /> ❑ SEEPAGE PITS WIDTH R LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft L. <br /> fir <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. ,T <br /> UR ADVANCE NOTICE REQUIRED FOR INSPECT ONS—PLEASE.CALL(209)953-7697 <br /> SIG TITLE `^' `r DATE <br /> A UI C U 1Y <br /> M <br /> NT <br /> PI <br /> r <br />