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ONSIITE WA' 'EWATER TREATMENT SYS AM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER A,C -3"°FL-STOCKTON CA 95202 - (209)468-3420 � <br /> 'IM <br /> NON-REFUNDA E MIT CALL k24M 953 97 FOR INSPECTIONS EXPIRES 1-YEAR FROM DATE ISSUED <br /> i <br /> ' JOB ADDRESS ITY/ZIP <br /> f. > <br /> � m <br /> CROSS STREETAPNI!qlPARCEL SIZE a <br /> l 1 <br /> OWNER NAME H <br /> b <br /> PONE <br /> OWNER ADDRESS <br /> CITY/STATE/ZIP <br /> CONTRACTOR `�. rr HONE <br /> CONTRACTOR ADDRESS �GITY/ST` E/ZIP <br /> LICENSE C 42 ❑C46 OTHER NUMBER EXPIRATION DATE <br /> ' uM1?',rYWAT.E►t4TAaLE DEPTH: IM ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> Y <br /> FERC TEST # r BUILDING PERMIT# LAND USE APPLICATION# <br /> "'"TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/iLiFGCAPACITY gal #OFCOMPARTMENTS <br /> © GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL 21190 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE 11 TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> :! ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES <br /> LENGTH OF LINES f} <br /> G DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ' FILTER BED WIDTH ft LE GT ft DEPTH <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION ft PROPERTY LINE 4— fj <br /> ❑ MOUNDED WIDTH <br /> 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 <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft c <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft, PROPERTY LINE ft c< <br /> `° ❑ _SEEPAGE PITS NUMBER WIDTH ft 'DEPTH tj <br /> DISTANCE TO NEAREST WELL $ FOUNDATION ft PROPERTY <br /> LINE ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> �I ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> INIMIY 24 HO. R V C N C RE UIRI:D FOR'INSP LEASE' AL 4)953-7697 <br /> i` 7 <br /> r SIGNED II TITLE <br /> DATE ' <br /> i <br /> r. <br /> i <br /> i <br /> I <br /> 1� DEPARTMENT U5 ON Y �{ <br /> Application Accepted By. _ Date `- l' t✓ Area Employee 1D# '737 <br /> Final Inspection By M Date 4/2/T� El SPECIAL PERMIT-Approved 6y <br /> Character of Soil to Depth of 3 Ft:J Pit/Sump Soll Character: <br /> COMMENTS *F.0 I aT c�F c.r�.eta i4 - 3c�`Zl✓ a cs <br /> '4 f2i,wA <br /> N <br /> PE SC Received eck#/ Amount Permit/ <br /> Code ;;INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 42-02-ODI ONSITE WASTEWATER PERMIT <br /> k2/22l2403 <br /> i6 <br />