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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-77/697 FOR INSPECTIONS EXPIRES.1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /L- CITWZIP v' ' <br /> /yf/p /ff�J IT6�C APN -- 1? PARCEL� PARCEL SIZE �C <br /> CROSS STREET 2* C <br /> s . <br /> OWNER NAME PHONE <br /> OWNER ADDRESS �� �/71�VJ�-- S CITYISTATEIZIP <br /> CONTRACTOR PHONE 14 <br /> 5 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE LL� <br /> WATER TA F DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y @ <br /> ❑ PERC TEST # BUILDING PERM€T##4g tits l Cal>—LAND USE APPLICATION#F @ <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED lALTERNATIVE <br /> ❑ REPLACEMENT ❑: DESTRUCTION <br /> i <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: rr rt AtB MPLa EE5:, <br /> SEPTIC TANK TYPE/MFG //c� L r' CAPACITzml al p PA <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY, I I lit rn a`I #��FP,edRvT�MIf�T� <br /> ❑ PKC TX PLANT DiSTANCE'TO NEAREST: WELL ft POUNDATIO 14r = PROPER Y,DINE f _ ft <br /> Clted <br /> _ LEFT STATION SIZE TYPE OF PUMP ElSAby ­-viND OIL SENA TOR(EnC oSeD SYSTEM) <br /> ❑ LEACH LINES ! LEACHING CHAMBERS /�1� 1�//Zfy,/jj, #OF LINES :�2� LENGTH OF LINES�//SCJ / ft <br /> r DISTANCE.TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> D FILTER BED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft CN <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> PSIE TS R I THD15T CF. L ft IPE Y LINEFOUNTY <br /> 1 ',REBY CERT Y TH HA P H N,11)T XOFO T AN J UIy 1 <br /> O IN S, AT AWS RULES AN I <br /> /MINIMUM OUR D NCE NOTIC SQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 k <br /> SIGNED U/ ��(�Z TITL G DATE r-••:�- <br /> i <br /> R <br /> E <br /> � U <br /> i TT <br /> A <br /> I <br /> 4 <br /> �f <br /> N' <br /> 1 <br /> �DEPARTMENT U.E O_LY,. <br /> Application Accepted By� Date 3 Area Employee <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Sail Character: y <br /> COMMENTS n1 s l t -mac..•c/ '7 -f�5� . - <br /> PE SC Receivedheck#! Amount Date Permit! Invoice# Permit[D# <br /> Code INFO B Remitted Service"nest# - A <br /> *-2-./-3 117 32o.t7D 3 p - D Y,D <br /> 1 <br /> 42-02-001 - - ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br /> a <br />