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. <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT `r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS ' -EXPIRES l YEAR F M TE ISSUED , <br /> "`JOB ADDRESSCITY/ZIP ye <br /> //JJ3 m <br /> CROSS STREET APN A? — PARCEL SIZE - C <br /> r- Q +� v <br /> OWNER NAME `Y C PHONE 1aQ]— � <br /> OWNER ADDRESS l // f CITY/STATE/ZIP I <br /> l" <br /> CONTRACTOR e.V/g/ � PHONE <br /> CONTRACTORADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED[ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: - <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 4 <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES / _--_- LENGTH OF LINES gnu ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 /> r" <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 ft DEPTH ft <br /> ' DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> D SEEPAGE PITS NUMBER WIDTH ft DEPTH ft ., <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft" <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> RDINANCES,S 5 AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MrgMUM 4 HQJl1R AD ANCE N ICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> 5 <br />�-- -� — .� --, - - DEPARTMENT-SE- } <br /> % <br /> Application Accepted B_ Date Area Employee 1D# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> C !�MENTS <br /> PE SC Received Chec Amount Per tl <br /> Date Invoice# Permit iD# <br /> Code. INFO B ash Remitted Service Request# r� <br /> g;RDC) L4 Logs <br /> 42-02-003 , _ �^� ONSITE WASTEWATER PERMIT <br /> kr.,12/22/2003 <br />