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16r-o-- 0301:P3j& <br /> �b ONSITE WASTEWATER TREATME ' SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"'FL-STOCKTON CA 95202 -(209)458-3420 <br /> - -NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS ������ S� >< � CITY/ZIP- <br /> CROSS <br /> ITY/Z.IP 'q <br /> ( _ / _ MIN PARCELSIZE a <br /> CROSS STREET ��r1�L.wi Yl� � C <br /> � J 0 <br /> OWNER NAME _ [J�9_ !S'c%/fV_-_-_P-_R j, PHONE <br /> 1 CITYISTATE/ZIP <br /> OWNER ADDRESS i�!�• <br /> CONTRACTOR <br /> PHONE 7i1�f-�C1Ti� <br /> CONTRACTOR ADDRESS /.'sVESs 191./JC_ CITVISTATE/ZLP <br /> LICENSE t�C-42 ❑C-36 OTHER NUMBER EXPIRATION DATES/-,./ <br /> WATER TABLE DEPTH: fl GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> Q PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: td, NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNEDIALTERNATIVE <br /> E Q REPLACEMENT ❑ DESTRUCTION <br />` INSTALLATION WILL SERVE: 1�RE51DENcu ❑ COMMERCIAL ❑ OTHER <br /> I NUMBER OF LIVING UNITS: ! J NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: <br /> SEPTICTANK TYPFJMFG �f l_ CAPACITY 111,M gal #OFCOMPARTMENTS 9 <br /> Q GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> f f <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL WlY— fl FOUNDATION g'E _ fl PROPERTY LINE J S ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES U LEACHING CHAMBERS #OF LINES _-.� LENGTH OF LINES ' It <br /> DISTANCE TO NEAREST WELL /576t ft FOUNDATION ft PROPERTY LINE `7 fl <br /> ❑ FILTERBED WIDTH ft LENGTH R DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q SUMPS WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE it <br /> J ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH ft <br /> p DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> I 1� SEEPAGE PITS WIDTH <br /> II � 3� R LENGTH fl DEPTH Fl <br /> DISTANCE TO NEAREST WELL /SD r ft FOUNDATION t ft PROPERTY LINE 7r It <br /> I HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> l F r MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)957-7697 <br /> i4R I <br /> SIGNED TITLE I�if�ci� DATE -pf <br /> L. <br /> 11 1 Al <br /> 42 <br />' f <br /> a <br /> tP r <br /> 4 <br /> f <br /> r ( <br />'r I <br /> I PU UG TN pNl I <br /> EN <br /> DEPAR T US ON Y �'fqQ <br /> Application Accepte*Deptof <br /> Dat¢ _ Area Employee FD# !!WW 1 <br /> F, Final Inspection By Date �J ❑ SPECIAL PERMIT-Appmvcd by- <br /> Character of Soil to : Pit/Sump Soil Character: <br /> COMMENTS �e i <br /> i <br /> s <br /> PE Sc Received Che I Amount Permitl <br /> Code INFO B as Remitted Date Service Request# Invoice# Permi110# <br /> ITt2ar�3 I <br /> a2-B I.Da 1 <br /> �A,�� ONSITE WASTEWATER PERMIT <br />