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ONSITE WASTEWATER TREATMENT SYSTEM <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3'0 FL-STOCKTON CA 95202 - (209)xli4 20 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> ILI € <br /> JOB ADDRESS _ /pp CITY/ZIP � .l�(.._- U <br /> "LL t - APN (�.J �7 C" Q PARCEL SIZE �k <br /> CROSS STREET L C <br /> � _ <br /> OWNER NAME "? `1 �. �4' I PHONE <br /> OWNER ADDRESS <br /> CITYISTATEIZIP <br /> _ - (fes <br /> CONTRACTOR PHONE <br /> CONTRACTORADDR£SS r/ 1'` CTTY/STATE/ZIP <br /> O' <br /> LICENSE C 42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COOrdinatts X Y <br /> ❑ FERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ,tJ�REPMR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> l-v�NUMBER OF LIVING UNITS: �7 NUMBER OF BEDROOMS: +��,' NUMBER OF EMPLOYEES: <br /> Nd EPTIC TANK TYPE/MFG c T CAPACITY C��t9 gal #OF COMPARTMENTS -._r1 C <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETONEAREST: WELL ft FOUNDATION IE3 ft PROPERTY LINE /C�C7 / ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> / er <br /> ❑ LEACH LINES LEACHING CHAMBERS_ #OF LINES LENGTH OF LINES 7 ft <br /> DISTANCE TO NEAREST WELL l ft FOUNDATION _ ft PROPERTY LINE <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <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 ft PROPERTY LINE ft <br /> 0 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAR7T WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 13 SEEPAGE PITS NUMBER WIDTH WIDTH S� ft DEPTH y ft <br /> DISTANCE TO NEAREST WELL Sit ft FOUNDATION c � ft PROPERTY LINE / ft <br /> IN.EREBY CERTIFY THAT VE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> DINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIN 24 HOUR A ANCE N ICE REQUIRED FOR INSPECTIO S—PLEASE CALL(209)953-7697 Z <br /> SIGNED TITLE DATEla, PI <br /> s <br /> 4 , <br /> r <br />�I <br /> r <br />