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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 7 C 54ff-s zA q5 21 S <br /> JOB ADDRESS 1� ��) G: ^�j CITY/ZIP <br /> CROSS STREET i PIN 103— -G7 PARCEL SIZE I�� v <br /> OWNER NAME / YI. U4/ o w,as PHONE <br /> �' <br /> OWNER ADDRESS " co3q E A�^y' V e CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PER TEST # � BUILDING PERMIT# LAND USE APPLICATION#Oto - 0 Hck <br /> I <br /> TYPE OF WORK: LI NEW INSTALLATION ❑ REPAIR/ADDITION Ll ENGINEER DESIGNED ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ED 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 /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES 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 /> 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 /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 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 /> MINIMUM 24 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLF SE CALL(209)953-7697 <br /> SIGNED <br /> TITLE G�G� /C.�\ DATE 2 f _ <br /> � � s <br /> --50 <br /> s <br /> PAR $ <br /> SCALE I"=50' /� � V I „ y,•,v <br /> $ss <br /> 0' <br /> 50' 100' 150' w� � OESIGN4TE0 REMAINDER <br /> 8 <br /> 8 0 <br /> 1w iN UN Ty <br /> ArTF <br /> $ PARCEL 2 <br /> sTv io3 zoo-os 2 r1�CHg 4� <br /> a <br /> aI AQ4 so.ao AVE9� - <br /> zu.m• <br /> DEPARTMEN�IT USE ONLY <br /> Application Accepted By,./ � g� - Date 1''Z--()f' Area Employee ID# _ <br /> Final Inspection By y`__ Date �4&3LCtl ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: t& Pit/Sump Soil Character: <br /> COMMENTS J N_ �� 3 =.�'.S1al;vl�. :__ —e x..8'9 .�. ��=gym.t !/• <br /> Men ? <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By as Remitted Service Request# <br /> ONSITE WASTEWATER PERMIT <br /> 42-02-001 <br /> 12/22/2003 <br />