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ONSITE WAST'P.WATER TREATMENT SYS7"M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ATMENT 304 E WEBER 6"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT 7 <_%-ALL(209)953-7697 FOR INSPECTIONS � EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS // 1 Z 7 (/ 10 i, CITY/Z[P G � =1 <br /> CROSS STREETAPN 2-5 ! C)Q <br /> PACEL SIZE � <br /> 1 <br /> OWNER NAME / � PHONE � <br /> OWNER ADDRESS d CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS ` y�� `J jYxr(J7Lr� CITYISTATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y `l <br /> ❑ PERC TEST(S) NUMHER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑, ENGINEER DESIGNED/ALTERNATIVE lzC <br /> ❑ REPLACEMENT I ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ,t NUMBER OF EMPLOYEES: /( [ <br /> ❑ SEPTIC TANK TYPEIMFG Z_ - J CAPACITY.__,;; , 6al #OF COMPARTMENTS _J <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 #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELLft (FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH �� ft LENGTH ' ft DEPTH y� ft t\' <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft \� <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft �J <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 R <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH 11 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE H <br /> 0 SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 1 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 /> INIIMM M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> SIGNED� jr—�a��,� TITLE DATE�y U L_ <br /> I <br /> U� <br /> e' <br /> t Z <br /> V <br /> PAY - T <br /> IVED <br /> k� <br /> IN <br /> �-cy T D A E <br /> DEPARTMENTp USE ONLY <br /> Application Accepted By /'"f Date���/� 3 _ Area Employee ID# t <br /> Final Inspection By Date� SPECIAL PERMIT-Approved by <br /> Character of Soil to Dep h of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE Sc Received hec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> 42-01-001 r y <br /> 1212/02 ONSITE WASTEWATER PERMIT <br />