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ONSITE WA,,,,EWATER TREATMENT SYS �/'M PERMWANNED <br /> A <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER VE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS -A?6 53 �JSour TN m4/V 7-11g5V Ro q.j9 CITY/ZIP 4,47-/4,41!0/2 <br /> CROSSSTREET KLO 20�}D APN /9/- 130—D7 PARCEL SIZE 3�{• o <br /> OWNER NAME I'VD)p W kkeY_ /A",PEQTIEr PHONE -40 8- 262- 14 10 <br /> OWERADDRESS 133 ✓OTNY`OAVL. CITY/STATE/ZIP A/`IO/TA� 614 9-5'19,70- <br /> 1 <br /> 5 0,! 0y <br /> CONTRACTOR PHONE '/ <br /> CONTRACTOR ADDRESS 45 OX CITY/STATE/ZIP RLOG CA <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # Cw BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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 /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASETRAP 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 it FOUNDATION it PROPERTY LINE it N <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft c�, <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> G <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST ' WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft ) <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft A <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft j <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft 2 <br /> ❑ SEEPAGE PITS NUMBER _ WIDTH ft DEPTH ft x <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R rt <br /> 1.i <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY j <br /> DI NA NCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIN 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE OA Ae0X DATE -/L -OL <br /> 1 E <br /> El <br /> R <br /> N <br /> AN M <br /> T <br /> + EIEPARTMENT�U/$E ONLY 3/ <br /> Application Accepted By Date <br /> ,3 I 1 V/� Area Employee ID# 737? <br /> 9< <br /> Final Inspection By - Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/SumpSoil Character: <br /> COMMENTS _ d1,2 &A5 s�c 1eJ d To :9, a }� t{7 6 aAxg a/asvyl/ee��l <br /> a Yr� „ssr� .tYo�y/ 2y �' 1y. 2 aL _7� / uz <br /> - <br /> PE Sc Received Checkil/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service Re ues[# <br /> 42--uS2 �fi qC7 1n.eD WDA- <br /> 0 17 <br /> ONSITE WASTEWATER PERMIT <br /> 42-02-001 <br /> •1222/2003 <br />