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R1�'F ONSITE WASTEWATER ATMENT SYSTEM PERMIT <br /> IAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT304 E WEBER AVE-3"FL-STOCKTON CA 95202 -(209)20 <br /> NON-REFUNDABLEEr,�PERMIT CALL(109)953-1x97 I-OR INSPECTIONS EXPIRES� { <br /> I VrAR FROM DATE ISSUED <br /> Jon ADDRESS tJ I GrYl21P W�� 1 I_c i..u_ 1's `'-1 <br /> :ROSS STREET fl 1>£ APN �'a�-` � — PARCEL SIZE ,l¢P <br /> o <br /> —JWNER NAME I�iG ITh � il✓VI CI� - PHONE <br /> w <br /> OWNER ADDRESS CITYISTATEIZIP <br /> 11 �1I <br /> CONTRACTOR N l.'I• ! 6, 1 ll —t `in- � I� 11L�IC�F`..� —JLr_P is PHONE j 6 <br /> 1—CONTRACTOR ADDRESS if pi IgayI CITYISTATEIZIP L—L J (A Z �,1>> <br /> t <br /> LICENSE LI C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE 1�I <br /> U' <br /> WATERTABLE DEPTH: ft GEOGRAPHICALINFORMATION: Coordinates X Y <br /> PERC TEST # SUILDINC PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNEDIALTLRNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION _ <br /> I NSTALLATION WILL SERVE; Q RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> Y NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPFJMFO CAPACITY gal 4 OF COMPARTMENTS <br /> ❑ GREASE TRAP "TYPE/MFG CAPACITY, gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION R PROPERTY LINE ft <br /> JI } <br /> �] LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH or LINES ft <br /> «i <br /> �+ DISTANCE TO NEAREST WELL R FOUNDATION fl PROPERTYUNE ft F <br /> :7 FILTER BED WIDTH R LENGTH ft DEPTH <br /> -tea. DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION A PROPERTY LINE it(;i <br /> ❑ SUMPS - WIDTH R LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL it FOUNDATION R PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft LFNGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ftY� <br /> 5 <br /> l❑ SEEPAGE PITS NUMBFR WIDTH R DEPTH - R '"- <br /> 4 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> HEREBY CERTIFY THAT 1 HAVE PREPARED TBI$APPLICATION AND THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> .MIN1MUM 24 HUUR AIR'AN'CE NUl'ICF.REQUIRED FOR INSPECTIONS PI-t:ASF CRL1,('U9)95J-7h97 <br /> F1111 /",, !SGNED 1 fr a t'' �� � TITLE/sFr''"C C' DATE <br /> 1 <br /> I _ <br /> i <br /> I <br /> T <br /> 'c <br /> 0 <br /> 1 J O 1 <br /> N <br /> i <br /> t <br /> DEPARTMENT IJ E 0 C� (/ <br /> Application Accepted By ,�— 1�. ""�• Date I�1° US Area Z 1 6 Employee ID# 'x Y 7 <br /> Final inspection By Date ❑ SPECIAL PERMIT-Appmved by <br /> (Character of Soil to Depth of 3 Fc PiUSump Soil Character: <br /> .,COMMENTS <br /> PE SC Received Check#1/ Amount Pitt <br /> J•� Code INFO B J9 emitted Date Service Request# Invoice tf Permit ID# <br /> - w z.z z- s>! � 5'I Z— ?3. 1 r i'•S 5 U U 4 L7 <br /> I <br /> 4212-001 ONSITE WASTEWATER PERMIT <br /> 12!22/2003 - ` - <br /> F� _ <br />