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7 3i <br /> r. ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"°FL-STOCKTON CA 95202 - (209)4638-3420 <br /> '^NON-REFUNDABLE PERMIT CALL.,(209)953-7697 FOR INSPECTI , EXPIRES i YEAR FROM DATE ISSUED 42 <br /> -'JOB ADDRESS -711+7 4f W V' Q yK IT ZIP ! M <br /> e3 ((( APN CS91 �(7�7 a <br /> CROSS STREET PARCEL SIZE _ C <br /> PHONE 3(e[O r r=9 p /�---- <br /> j OWNER NAME - I Le --- <br /> +O WN ER ADDRESS CITY/STATE/ZIP �] <br /> s CONTRACTOR C� PHONE - ��O <br /> . Y CONTRACTOR ADDRESS CITY/STATEEIIZIIP�_C I <br /> LICENSE C-42 ❑C-36 OTHER NUMBER :4 ?0 7`7 EXPI RAT10N DATE <br /> r WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> f <br /> 'TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION ElENGINEER DESIGNED/ALTERNATIVE <br /> 1 1 ❑ REPLACEML'NT LI DESTRUCTION <br /> �,-INST�ALLAT�IONWIL�LSERV�F-.: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: �} NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG Q CAPACITY OC) gal #OF COMPARTMENTS <br /> R+, Q GREASE TRAP -TYPE/MFG YPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> © PKG TX PLANT DISTANCE TO NEAREST: WELL f F0 R FOUNDATION /-5- ft PROPERTY LINE S ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> E� / � <br /> LEACH LINES Ll LEACHING CHAMBERS, #of LINES _ „LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL /C)O ` ` ft FOUNDATION_ ft PROPERTY LINE f f ft <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 /> l 1. ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> w DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH_ ft <br /> F DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS WIDTH ft LENGTH ft DEPTH_, ` ft <br /> DISTANCE TO NEAREST WELL t��Q r ft FOUNDATION—an t ft PROPERTY LINE rte;/ ft <br /> ' + I HERF43Y CERTIFY 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 y TITLE DATE Z <br /> s <br /> k <br /> �., .1.11 Ib <br /> r . <br /> nj <br /> - s <br /> F ; . <br />