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�i. <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN J04QU IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3RO FL-STOCKTON CA 95202 -(209)468-3420 <br /> I` NON-REFUNDABLE PERMIT 1 CALL 2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 Jou ADDRESS �1"�i lcO L G' . ii ...1ci - CITYIZIP 11�-- ,r m <br /> -; � ` PARCELSI7CROSSSTRFET APN Jr2E <br /> •I: F7 p <br /> ( p <br /> p JJ ! <br /> OWNER NAM!: I Y?"'y F f.ry IF <br /> OWNF.RADDRESS CITYISTATFIZIP k <br /> .I l <br /> CONTRACTOR '(- ' !'� PHONE <br /> I CONTRACTOR ADDRESS C'1ip-i "-1 1, _rte, .. �'��., CITYISTATEIZIP1 �.1,- r-4- <br /> F yyyM 1 LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH; ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST 9 BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW I NSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> A ,y ❑ REPLACEMENT ❑ DESTRUCTION <br /> 7 INSTALLATION WILL SERVE: ❑ RESIDENCE Q COMMERCIAL ❑ OTHER <br /> 1t F NUMBENOFLIVING UNITS: NDMSER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPEIMFG CAPACITY gal II OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal 4 OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE To NEAREST: WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ LEFT STATION SIZE TYPE OF PUMP LI SAND OIL SEPARATOR(ENCLOSED SYSTEM) �- <br /> { ❑ LEACH LINES ❑ LEACHING CHAMBERS #OFLINES LENGTH OF LINES R I }' <br /> #1 DISTANCE TO NEAREST WELL R FOUNDATION fl PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R ' <br /> �P ❑ MOUNDED WIDTH R LENGTH f, DEPTH ft <br /> i DISTANCE TO NEAREST WELL R FOUNDATION R PROPERFY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH fl DEPTH <br /> } DISTANCETO NEAREST WELL R FOU NIIATION R PROPERTY LINE R <br /> 4 Y ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH <br /> DISTANCETO NEAREST WELL R FOUNDATION R PROPERTY LINE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> 1' + ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> j <br /> A �MINIMUNI 24 HOUR ADVANCE NOTICE REQUIREDFOR INSPECTIONS-PLEASE CALL(20q)993-7697 <br /> {. SIGNED _! -.-- r r -T TITLE :.-r.r '}-rc,..,"TDATE <br /> F, <br /> r <br /> 1�✓ <br /> I <br /> r CII- <br /> Tp EN <br /> � I I <br /> I ATL <br /> y xD n <br /> l 7 , r <br /> 1 DEPARTMENT SE O�Y <br /> PP P y r ' E ` Z' (�(�" Area Employee ID# <br /> A licafion Accepted B '! ;r�7-�_ '� ,,.:�'�-�_ Dale r � 7 ! <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> 4 Character of Sol]to Depth of 3 Fl: Pit/Sump Soil Character: <br /> COMMENTS <br /> i �. PE SC Received Cheek#/ Amount Dat Permit/ Invoice# Permit I DIE <br /> Cade INFO $ . s Remitted Service Request# <br /> y zz S / �');� ,n 6 l x /11 9 4� <br /> f <br /> fir <br /> ' 42A2-001 ONSITE WASTEWATER PERMIT <br /> 1212272003 <br />