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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> NON-REFUNDABLE PERMIT304 E WEBER AVE -3"D FL-STOCKTON CA 95202 - (209)468-3420 <br /> CALL 209 953-7697 FOR INSPECTIONS <br /> JOB ADDRESS �a•. � � � n � a EXPIRES I YEAR FROM DATE ISSUED <br /> CROSS STREET <br /> p sL !I CITY/ZIP�k } g <br /> � _ <br /> APN �2 ZOO �� � <br /> [,OWNER NAME PARCEL SIZE <br /> OWNER ADDRESS PHONE_ [� <✓I <br /> S CITY/STATE/ZIP )� y <br /> CONTRACTOR <br /> PNONE <br /> CONTRACTOR ADDRESS <br /> CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER <br /> WATER TABLE DEPTH: NUMBER EXPIRATION DATE <br /> ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> ❑ PERC TEST # BUILDING PERMIT• NEW I # Y <br /> TYPE OF WORK LAND USE APPLICATION# <br /> INSTALL LIREPA►R/ADDITION <br /> ❑ REPLACEMENT ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> INSTALLATION WILL SERVE: RESIDENCE L3 DESTRUCTION <br /> NUMBER OF LIVING UNITS: <br /> ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG r" `.� /' (�(� <br /> /'r�lLC irk CAPACITY I d-Q 1 1 <br /> ❑ GREASE TRAP TYPE/MFG- � gal #OF COMPARTMENTS_ <br /> CAPACITY gal #OF COMPARTMENTS—_ <br /> 13PKG TX PLANT DISTANCE TO NEAREST: WELL�t o <br /> ft FOUNDATION G�'_ ft PROPERTY LINE <br /> ❑ LIFT STATION, SIZE ft <br /> • — TYPE OF PUMP ❑ SAND OIL SEPARATOR <br /> C (ENCLOSED SYSTEM) <br /> ❑ EA �LINE�S ���ERS <br /> #OF LINES <br /> L3 FILTER BED i <br /> DISTANCE TO NEAREST WELL I ft FOUNDATION LENGTH OF LINES S ft <br /> WIDTH ft ft LENGTH �— PROPERTY LINE <br /> ft ft <br /> f DISTANCE TO NEAREST WELL ft DEPTH ft <br /> ❑ MOUNDED ---- FOUNDATION ft <br /> WIDTH PROPERTY LINE <br /> ft ft LENGTH ft <br /> DISTANCE TO NEAREST WELL DEPTH ft <br /> `SUMPS ------- ft FOUNDATION ft <br /> WIDTH R LENGTH PROPERTY LINE <br /> ft ft <br /> DISTANCE TO NEAREST WELL DEPTH ft <br /> LJ DISPOSAL PONDS WIDTH ft FOUNDATION ft PROPERTY LINE <br /> �- ft LENGTH ft <br /> le 64t"�I <br /> DISTANCE TO NEAREST WELLft DEPTH <br /> ft FOUNDATION ft <br /> LJSEE AG PITS NUMBER 2' WIDTH ft PROPERTY LINE ft <br /> 3 <br /> DISTANCE TO NEARESTWELL ft DEPTH -a <br /> �_ ft FOUNDATION ft <br /> 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 /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MUM 24 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE r-- <br /> DATE I q — 0 S <br /> i <br /> 1 <br /> N � <br /> I <br /> I <br /> P R a <br /> - N <br /> DEPARTMENT URE O LY <br /> Application Accept <br /> to — <br /> Final Inspectio Area Employee ID# <br /> Character of Soil to th of 3 Ft: Date ❑ SPECIAL PERMIT-Approved by <br /> COMMENTS, P'VSump Soil Character: �— <br /> 23 l DoLAA L <br /> PE SC Received Che <br /> Code INFO Amount Permit/ <br /> Cash Remitted Date <br /> Service Re uest# Invoice# Permit ID# <br /> Z <br /> -001 <br /> .412003 <br /> ONSITE WASTEWATER PERMIT <br />