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1 �yI ONSITE WASTEWATER TREATII�T SYSTEM PERMIT <br /> 1 SAN JOAQUI�VTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3-FL-STOCKTON CA 95202 -(299)469-3420 <br /> FFF <br /> NON-REFUNDABLE PERMIT CALL(209)953-76197 FOR INSPECTIONS 1EXPIRES 1 YEAR FROM DATE ISSUED <br /> a f'." s CITY/zIP r A i G. (�� e7 <br /> JOB ADDRESS ( s=i-'"� tl. 7 $ ..�. � r �`- `'�" _ ,'" . <br /> . T'.`- AIN I - i�r - .� PA+RCEL SIZE <br /> CROSS STREET <br /> I OWNER NAME `"7 t'. �" ( � PHONE <br /> i OWNER ADDRESS i'"i ' "� Imo•'- "f'r' CITY/STATEIZIP F 1,-a - '�: C 'y'' 1 <br /> CONTRACTOR �-� •') i'C PHONE <br /> CONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE L1C-42 ❑C-36 OTHER NDMHER EXPIRATION DATE <br /> WATER TABLE DEPTH: it CEOGRAPHICALINFORMATION: C'oordinRtes X Y <br /> .� PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION LIREPAIRIADDITION 13 ENGINEER DESIGNED(ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCr1ON <br /> INSTALLATION WILL SERVE: C1RESIDENCE COMMERCIAL ❑ OTHER <br />} NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> I ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> �j$i ! ❑ GREASE TRAP TYPE/MFG CAPACITY $RI #OF COMPARTMENTS <br />�I 1 - ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION fl PROPERTY LINE ft <br /> i <br /> g ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R <br /> DISTANCE TO NEAREST WELL— <br /> 0 <br /> FOUNDATION R PROPERTY LING ft <br /> f ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> w t DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> j ❑ MOUNDED WIDTH ft LENGTH fl DEPTH ft <br /> + \ <br /> '- DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ' I <br /> ❑ SUMP$ WIDTH fl LENGTH fl DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> 4 ' <br /> DISTANCE TO NEAREST WELL ft FOUNDATION $ PROPERTY LINE fl <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATIOk 8 PROPERTY LINE R <br /> f I <br /> I HEREDV 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2091953-7697 <br /> r-- r <br /> ' ? Z <br /> I SIGNED T�- LRe-�-.-�._..�- _ u<..., 1 F F-"-- _.-TITLE. ^•�` �.... _�...-. '3�..J--- _ DATE i •..% <br /> ,r i! <br /> I <br /> l <br /> rs k.? <br /> P i � <br /> FA <br /> I <br /> Q ! <br /> [); <br /> # E fti M <br /> i <br /> ` DEPARTMENT USE ONLY _ <br /> f <br /> Application Accepted Sy '{c_ r.'- Date r r U` Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> IE F Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> 1 r�; <br /> PE SC Received C_;heck#�1 Amount Permit! <br /> ' Date Invoice# Permit IDN <br /> Code INFO B Cesh Remitted Service Request# <br /> t 42-02-001 ONSITE WASTEWATER PERMIT <br /> 1212212063 <br />