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�J ONSITE, WASTEWATER TREATMENT SYSTEM PERMIT <br /> -SAN JOAQUIN Cot N I'YENVIRONMENTAL HFALTII DEPARTMENT 304E WEBER AVF -11"°FI.-SIOCK'TON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMhr C'A1.1,(209)953-7697 FCTR INsPI.c riw s EXPIRES 1 YEAR FROM DATE ISSUED <br /> r drA <br /> JOB ADDRESS 'E '.��- '1!uiy j L,4"1 C/l -'� __ CITYYZIP _. J �_� G./�t P <br /> - G I � <br /> CROSS STREET ,1 APN / 7- �'`/�( `/ _ PARCEL SIZE f p <br /> OWNER NAME -, /✓_ �i m/xH PHO'wF. --- fn <br /> OWNER ADDRESS �� / � ��� L�L� �� ��ll CITY/STATE/ZIP <br /> CONTRACTOR / L•G<< _ PHONE1� <br /> CONTRACTOR ADDRESS CITY'/STATE/ZIP <br /> LICENSE MC-42 LI C-36 01111.R ._ .. NUMBER _ EXPIICATION DATE <br /> WATER TABLE DEPTH: If GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION <br /> TYPE OF WORK: ..1 NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACENIFNT _ J DEST'RUCT'ION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMME.RCIAL. U OTHER <br /> NUMBER OF LIVING UNIT'S: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG _ CAPACITY gai #OFCOMPARTMEN'S _ <br /> ❑ GREASE TRAP TYPE:/MFG CAPACITY gal if OF Com PARIMENTS__. <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOI1NDAr1GN Il PROPERTY LINE Il <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENC ,c "TEM) <br /> :3LEACH LINES LEACHING CHAMBERS #or,LINFS_1 LENGTH OFL FSI 5LI11 —E <br /> DISTANCE TO NEAREST WELL fl FOUNDATION _ fl PROPI'RTY LI <br /> Ai <br /> ❑ FILTER BED WIDTH ft LENGTH it DEPTH fi U <br /> DISTANCE TO NEAREST WELI- ft FOUNDATION R PROPERTY LINE fl f`n <br /> ❑ MOUNDED WmTH__ ft LENG111 R DEPTH ft <br /> DISIANCETONEAREST WELL ft FOUNDATION Il PROPERTYLINE ft <br /> ❑ SUMPS WIDTH III LENGTH A DEPTH R <br /> r <br /> DISTANCE TO NEAREST WFLL. A FOUNDAI V)" Il PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH tl LENGTH ti DEPTH fl <br /> DISTANCE TO NEAREST WELL 0 FOUNDATION Il PROPERTY LINE fl � <br /> ❑ SEEPAGE PITS NUMBER AA'IDTTf it DEPTH fl <br /> DISTANCE TO NEARF.SI %k El L A FOUNDATION ft PROPERTY LINF. fl <br /> I HEREBY CF.R'TIFY THAT I HAVE:PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE"ITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. C, <br /> IINIMUN 24 HOUR/ADVANCE NI)I IC'E:RE:QLIRED POR INSPECTIONS-PLEASE CALL(204)453-7h47 �y <br /> SIGNED �. _ �`✓ TITLEen s DATE <br /> I I I <br /> I <br /> � I � <br /> i I i <br /> C ' <br /> O <br /> I � <br /> 1 <br /> VI <br /> I� —:7, <br />