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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATEISSUED <br /> JOB ADDRESS � CITI'/ZIP " 4, m <br /> a <br /> CROSS STREETAPN t PARCEL SIZE o <br /> OWNER NAME �j <br /> OWNER ADDRESS '"'`' �^�— CITY/STATE/ZIP �n <br /> CONTRACTORL � C`.�l'� PHONE <br /> CONTRACTOR ADDRESS--:R,--/ -71 Y' L.0 ewcCV"( ` �j".(/_ CITY/STATE/ZIP <br /> LICENSE C-42 ❑C-36 OTHER NUMBER Y Y L�� EXPIRATION DATE (v <br /> WATER TABLE DEPTH: ft GEOCRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIWADDITION ❑ 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 gat #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #of LINES LENGTH OF LINES tt <br /> DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE ft <br /> i <br /> FILTER BED WIDTH �I ft LENGTH 70 ft DEPTH �CYn.t�o( ft <br /> DISTANCE TO NEAREST WELL,'0Q ft FOUNDATION ft C� ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <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 It PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH_ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Cl SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> I HEREBY RT '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. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED A TITLE DATE <br /> A <br /> f2r: <br /> n� <br /> n <br /> '1 <br /> co N <br /> S E �3 S p1 151 1 <br /> ON EN <br /> � t7 <br /> t <br /> 7 <br />