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003040 <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> - <br /> :SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3RD FL-STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERM LT,-w CALL(209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> > <br /> CROSS STREET 1A!',1. V1 APN j'7 PARCEL SIZE_ <br /> OWNER NAME PHONE q zi <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR ("e, PHONE <br /> \'z CITY/STATE/ZIP <br /> CONTRACTOR ADDRESS V�-Lf r-) <br /> LICENSE <br /> D C-42 LI C-36 OTHER NUMBER rEXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: Ll NEW INSTALLATION 13,-REPAIR/ADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> LI REPLACEMENT 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: W-RtSIDENCE ❑ COMMERCIAL El OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ra NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG C, "if CAPACITY CND gal #OF COMPARTMENTS <br /> 0 GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ DISTANCE To NEAREST: WELL ft FOUNDATION ft PROPERTY LINE <br /> PKG TX PLANT C ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES L] LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE To NEAREST WELL 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 /> El MOUNDED WIDTH —ft LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> El sumps WIDTH ft LENGTHft <br /> ft DEPTH <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> El DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION -ft PROPERTY LINE ft <br /> Ll 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 RULES AND REGULATIONS OF SAN JOAQUIN COUNTY <br /> E1ONS -'LEASE YC <br /> L(209)953-7697 <br /> TITLE <br /> gVA CA QUIREDFORINSP <br /> ?VA(MN0T1cERE 7 <br /> DATE <br /> ............. <br /> 52" <br /> aC <br /> S <br /> I I/ <br /> ID <br /> 1-4 <br /> I 1� <br />