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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 344 E WEBER AVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPE TIONS EXPIRES �RFROM DATE ISSUED <br /> fS�a <br /> JOB ADDRESS 1 CITY/ZIP <br /> zva <br /> APN PARCEL SIZE <br /> CROSS STREET <br /> OWNER NAME 4 d h Y,4 <br /> G[(tGci� PHONE fxOA': '731 - 31 51- <br /> r� I; W F`¢ [nJln4t CITYISTATEIZIP �'4:K'LT CA <br /> OWNER ADDRESS ,48 <br /> PHONE <br /> CONTRACTOR <br /> CITY/STATE/ZIP <br /> CONTRACTOR ADDRESS <br /> NUMBER EXPIRATION DATE <br /> LICENSE ❑C-42 ❑C-36 OTHER <br /> ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> WATER TABLE DEPTH: i <br /> ❑ PERC TEST # BUILDING PERMIT LAND USE APPLICATION# �! <br /> ❑ REPAIR/ADDITION ❑ EN INEERDESIGN IALTERNAT E �I) <br /> TYPE OF WORK: ❑ NEW INSTALLATION v <br /> ❑ REPLACEMENT ZW DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE <br /> ❑ COMMERCIAL ❑ &H E R �f f L .5 <br /> NUMBER OF LIVING UNITS: <br /> NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> r <br /> ❑ SEPTIC TANK TYPE/MFG <br /> CAPACITY gal #OF COMPARTMENTS I <br /> ❑ GREASE TRAP TYPEIMFG <br /> CAPACITY gal #OF COMPARTMENTS <br /> ft FOUNDATION ft PROPERTY LINE ft j <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL II <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) L <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft I <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ftj <br /> ft ft �, <br /> ❑ FILTER BED WIDTH ft LENGTH DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ft LENGTH ft DEPTH ft <br /> ❑ MOUNDED WIDTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SUMPS <br /> WIDTH ft LENGTH ft DEPTH ft <br /> ON ft PROPERTY LINE ft <br /> ft FOUNDATION DISTANCE TO NEAREST WELL - <br /> R <br /> Elft LENGTH DEPTH ft DISPOSAL PONDS WIDTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ft <br /> Ll SEEPAGE SEEPAGE PITS NUMBER DEPTH ft � <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ANCE <br /> 1 HEREBY CERTIFY THAT I HAVE <br /> PREPARED <br /> REP R STATE LAWS CATION AND THE WORK WILL <br /> AND REGULATION E DONNA <br /> E I ACCORD <br /> COUNTYWITH SAN JbAQU1N COUNTY <br /> ORD <br /> AND <br /> MINIMUM 24 HOUR ADVANCE.NOTICCE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> . � <br /> TITLE DATE <br /> SIGNED i } <br /> r r F-i--t-; a J <br /> J. . r <br /> ih. <br /> 4 . r_ . .., <br /> - O U <br /> - k N F r <br /> M <br /> DEPARTMENT USVONLY ` 01 I, / <br /> i `C;�._ Date � Area ��-�f Employee lD# L, <br /> Application Accepted By I f <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PitlSump Soil Character: <br /> COMMENTS f r <br /> jPE SC Received Chec Amount Date Permit! Invoice# Permit ID#IN <br /> B Cash Remitted Service Re uest# <br /> SIs V' � 1 <br /> ONSITE WASTEWATER PERMIT <br /> 42-02-001 <br /> 12/22/2003 <br />