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j <br /> ONSITE WAST"WATER TREATMENT SYSTYM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D*4,0,TMENT 304E WEBER A,,,aaIf3-`FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ( (ZQI ( n�Y <br /> CITY/ZIP <br /> CROSS STREET APN 12q <br /> ��QIQPARCEL SIZE 19' 61 <br /> ppP"0 ' T <br /> OWNER NAME BrOIf4 Klu(.,P PHONE <br /> dO <br /> F13O'D10 If r <br /> OWNER ADDRESS S4Y11 QI CITYISTATF/ZIP mum <br /> CONTRACTOR �)n Gl PHONE <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE --- <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEWINSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEME ❑ DESTRUCTION V <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: A,� NUM,BEER-OF BEDROOMS: am NUMBER OF EMPLOYEES: �- <br /> SEPTICTANK TYPE/MFO ��/lA)� �.1/hI CAPACITY 16/yW gal #OF COMPARTMENTS A <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY $a1 #OFCOMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION R PROPERTY LINE it <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) C <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES; ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION 0 ft PROPERTY LINE -700 it <br /> r <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH ft o <br /> DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE II .T <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH R <br /> DISTANCE TO NiAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS WIDTH - 1 ft LENGTH ft DEPTH ft <br /> ft <br /> DISTANCE TO NEAREST WELL ZOO ft FOUNDATION 10 ft PROPERTY LINE__?0y R <br /> 1 HEREBY 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 /> MINIMU51 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> SIGNED --< / TITLE DATE5_ `27-03 <br /> - -- <br /> i <br /> I <br /> 1 <br /> 1 <br /> SA I J A IN CO N <br /> Ifi <br />