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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> a3° <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHDEPARTMENT 304 E WEBER AVE -310 FL-STOCKTON CA 9$202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953--7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 0 8 7 3 W. �a2w l!1^ G 1'a V t JCy�� CITY/ZIP TNO}1y/`� <br /> -� <br /> m <br /> CROSS STREET APN 041 C��- �D� PARCEL <br /> ,S,I[ZE Z— �C�i'(� v <br /> OWNER NAME �/ 01�'�t /✓�©Dl� PHONE <br /> OWNER ADDRESS w ' Wa NUt 1"Fv't ID� CITY/STATFIZIP n O1'f7./' -C' <br /> CONTRACTOR A +N N-f4c L PHONEp t�! 7 6 -O d Q-L <br /> CONTRACTOR ADDRESS 3 hLot. CITYISTATEIZIP r0 C 4 to/j <br /> LICENSE L3 C-42 C-36 OTHER NUMBER Z j EXPIRATION DATE <br /> ATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALi ATION WILL SERVE: RESIDENCE ❑ COMMERCIAL:' ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gel #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> r_ <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES C3 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ` �© ft , <br /> DISTANCE TO NEAREST WELL Z'0.7 1' $ FOUNDATION O R PROPERTY LINE /U <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> L3 MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft . LENGTH ft DEPTH ft `f <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> [3SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R m� <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 /> IMUM 24 OUR ADV NCE NOTICE REQUIRED FOR INSPECTIONS--PLEASE CALL(209)953-7697 c { <br /> SIGNED _ TITLE v ;3 D IC DATE <br /> I <br /> _w <br />