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,r <br /> ONSITE WA'"`T'EWATER TREATMENT SYMEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL),,DEPARTMENT 304 E WEBr„AYE -3"°FL-STOCKTON CA 45202 - (209)45$-3424 <br /> NON—REFUNDABLE PERMIT CAI. (209)953-7697 FOR INSPECTIONS /EXPIRES 1 . EAR FROM DATE ISSUED <br /> �I <br /> JOB ADDRESS 8/) aliAa— <br /> CITY/ZIP Lr 1 C r/ <br /> CROSS STREET + Y,j �iy > <br /> APN J !1'"�7sJ .. �f � <br /> PARC L IZE �� 'f1C�•�C yX" a <br /> OWNER NAME <br /> "']] _ S� j T•--- :., _ PHONE � <br /> i OWNER ADDRESS /y�t� ]JQ y�r� ( o(, hm 0 CITY/STATE/ZIP �.OYy-, ��� C t�} I a 46 f y <br /> CONTRACTOR y r g �'`�� <br /> PHONE J 6 <br /> CONTRACTOR ADDRESS y < C CITY/STATEIZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE I <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# - - <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED(ALTERNATIVE <br /> LI REPLACEMENT •❑ DESTRUCTION _A <br /> INSTALLATION WILL SERVE: RESIDENCE El COMMERCIAL ❑ OTHER ---d <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <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 WELL ft FOUNDATION ft PROPERTY LINE Q <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft j <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 /> ❑ DISPOSAL PONDS WIDTH 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 R <br /> I HEREBY CERTIFY THAT I 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 /> MINI M U ADVANCE NOTICE REQUIRED FOR INSPECTI?WP,L�E�AS7CA!&� (200919j53-7697 9 0� <br /> SIGNED TITLE t r <br /> y - <br /> L H E I <br /> I - <br /> 1 <br /> jDE. M <br /> .. f I <br /> PARTENT USE O GLY / <br /> Application Accepted By _t ..Date 2 7 Y Area r, Employee ID# i f <br /> Final Inspection By Date k7A ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/ ump Soil Character: <br /> COMMENTS <br /> o. v <br /> A0/' <br /> PE SC Received c Amount Permit/ <br /> Date Invoice# Permit ID# <br /> Code INFO BCash Remitted Service Request# <br /> qa -co-,u <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12122/2003 <br />� t <br />