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iv <br /> ONSITE WV'-EWATER TREATMENT SYS-",,M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH1sEPAR'I'MF.NT 304 E WEBEL�,r -3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR RoM ATE ISSUED <br /> JOB ADDRESS 0 c'-)C)v IrA— CITTYIZIP .O.n <br /> CROSS STREET APN `ten I [l PARCEI.S17E A > <br /> a <br /> c <br /> OWNER NAM E PHONE m <br /> 00, <br /> OWNER ADDRESS CITYISTATFIZIP <br /> CONTRACTOR 4 PIIONE !y�3 6 If- F ?- <br /> CONTRACTORADDRF.SS CITY/STATE/Z1P RUkf C T� <br /> LICENSE, C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE_16)-4 to <br /> WATER TABLE.DEPTH: len ft GEOGRAPHICAL INFORMATION: Coordinates X y �r <br /> ❑ PERC TEST N BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE,OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION %E1NGZ1NDESH7:NFI)IALTERNATIVE <br /> ❑ REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: URFSIDFNCF ❑ COMMER16AL ❑ OTHER f <br /> NUMBER OF LIVING UNITS: - NUMBER OF BEDROOMS: _ NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG _ �� CAPACITY/,,?&-U gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACICY gal #OF COMPARTMENTS J <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL. �C� ft FOUNDATION_� Ft PROPERTY LINE: ft <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 fl FOUNDATION ft PROPERTY LINE ft G <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft � <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINF ft r1� <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft U <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND LES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> INI M 1 111 R E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 ! <br /> SIGNED TITLE DATE <br /> 1 <br /> -.'. <br /> r <br />