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ONSITE WAf"EWATER TREATMENT SY M PERMIT SCANNED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH'iJEPARTMENT 304 E WEBER n•VE -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 /> JOB ADDRESS �`7 /� .121 SCr Iq C4 CITYIZIP CnC - <br /> CROSS STREET /� APN PARCEL SIZE <br /> � <br /> OWNER NAME Ur7 �� 1�"'"L _ PHONE % <br /> OWNER ADDRESS i?f»y 1'-2-7 f CiTYISTATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS C[TYISTATEIZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y I <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITIO 21NGINEER DES GNED IALTERNATWE <br /> L3REPLACEMENT DESTRUCTION c <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE © COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: i 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 Sim TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES tt <br /> DISTANCET O 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 /> MINIM 2 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL.(209)953-7,697 <br /> SIGNE10 TITLE; « I/'P'Z� DATE- <br /> rh <br /> Xf <br /> 77 <br /> Aw <br /> �.,- ' <br /> IrF' <br /> i <br /> 1 <br /> u <br /> i' <br /> ENyjj0,4MEN <br /> EjLT. :DEPA <br /> ARTME-N-T-USE <br /> - hLV2 - - <br /> Application Accepted-By Area Employee ID# <br /> Final inspection By Date ❑ SPECIAL PERMIT-Approved by / <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> CQMMENTS r s cS�P� 'UL <br /> lures dy+.S <br /> PE SC Re iv d Che Amount Permit! <br /> Code INFO Cash Remitted ate Service Request# Invoice# Permit 1D# <br /> 07 <br /> 42.02.001 ONSITE WASTEWATER PERMIT <br /> 12122/2003 <br />