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a <br /> ONSITE WA _E <br /> WATER TREATMENT SY5 M PERMIT. SC�4kIk <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDAB E IT CAG 09 953-769 F INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYlZIP <br /> .3 <br /> CROSS STREET dw APN FARCE}L SIZE,..y ��C <br /> OWNER NAME /PHONE <br /> OWNER ADDRESS vv CITY/STATE/ZIP_rK%v 1 <br /> f � � PHON L- <br /> C <br /> CONTRACCOR <br /> CONTRACTOR ADDRESS r E/ZIP <br /> } <br /> LICENSE C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> I <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED JALTERNATIVE <br /> (3 REPLACEMENT LI DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ 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 EQ #OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R P RTY LINE ft <br /> FILTER BEP ®WIDTH ■Q ft LENGTH 7ft DEPTHJERft <br /> DISTANCE TO NEAREST WELL ft FO[SNDATION 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 /> 1 <br /> ❑ DISPOSAL PONDS--%VIDTH 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 <br /> '1 HEREBY CERTIFY THAT 1 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 /> 0 CMINI UM 2VT?1 09 N ICE REQUIRED FOR INS TI N -�PLE E L(209)953-7697 <br /> SIGNER TITLE DATE <br /> 17 4 <br /> VArm <br /> 4 <br /> ,< sv o a f,I o r i <br /> f E Vl O <br /> . 141V 1 -7 FLA in U11 <br /> I IL <br /> 4 <br /> Application AcceA Y DEP:►RDeMENT=13 � 0.� Area Employee - --4/ - <br /> pp ID# <br /> Final Inspectio By Date ❑ SPECIAL_ PERMIT-Approved by <br /> Character of Soil to Depth of Ft: Pit/Sump Soil Character: <br /> COMMENTS F[t.T1�- E!J ccs y0g,�. ./ �Tn� ?5o a aE�.�C •48[-E �S'pec s ae Q <br /> AZAU 01 9-l4C-0-3 3'0 P4,0 SQ-r Co -f m <br /> A <br /> EA-)P-(.o <br /> PE SC Received h.rk#1 Amount Date, Permit! 04-_Invoice# rmi # <br /> Code INFO B s Remitted Service Re nest# <br /> 42-1 lls <br /> 42-02-001 ONSITE WASTEWATER IT <br /> I F22/2003 <br />