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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"FL-STOCKTON CA 95202 -{209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)95J3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> h ! /V l�f A, -%ter I/ A CITYrzIP C! <br /> i JOB ADDRESS _.;h „ Y 7.� �. �.J <br /> CROSS STREET (�l':i (� f I <br /> 'h- �. .,- APN `.�tri°n — 0 J PARCEL SIZE {;.� r f•C <br /> {' OWNERNAME ..�/ !( u r(!i-Gf fJ.,/. <br /> f PHONE <br /> OWNER ADDRESS �!!/ <br /> fL <br /> CITYI$TATE(ZIP :7•. � <br /> CONTRACTOR I !I, ^ T+' <br /> PHONE -5 <br /> CONTRACTORADDRESS 'I'j- J-r1.�:r5 - !(.I,J CITYISTATFfZIPI r4j <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # y BUILDING PERMIT# " LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION <br /> Fill <br /> ❑ ENGINEERDESIGNEDlALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNTTS: NUMBER OF BEDROOMS: NDMBER OF EMPLOYEES: <br /> f7 ❑ SEPTICTANK TYPEIMFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> Q PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION H PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> a <br /> I ❑ LEACH LINES ❑ LEACHING CHAMBERS d 4O LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> F,$ <br /> DISTANCE TO NEARr WELL ft FOUNDATION ft PROPERTY LINE fl <br /> _$ ❑ MOUNDED WIDTH ft LENGTH fl DEPTH tl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE A <br /> ❑ SUMPS WIDTH fl LENGTH fl DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION flPROPERTY LINE <br /> A <br /> ❑ DISPOSAL PONDS WIDTH fl LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH it DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE R <br /> 4 <br /> ]HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> h ORDINANCES.STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> t 1 <br /> NUN M 24 HOUR .AN NOTICE REQUIRED FOR INSPECTIONS, <br /> CAI-1,(2139 953-7697 <br /> SIGNED !' -' TITLE Y! r r I`�f-"- DATE <br /> v <br /> ENT <br /> lut <br /> s � <br /> R i <br /> P S <br /> F / <br /> _ - <br /> To <br /> - .__..._._ _-.. H QlnH EP kAtME <br /> I <br /> lit <br /> I ) i <br /> ! — <br /> as <br /> DE PARTMENT IJSE 9NLY <br /> Application Accnpled By i- ����- Date —7/ G Atea Employee FDP f -7 <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth oT3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received ',Chid 7Lr Anrounl PermlD { <br /> Date <br /> Code [NFO B Cash Remitted Service Request#Fj <br /> Invoice# Permit ID# <br /> c!2. =? ,;2 7 t� c. r..j`�. 1`. .,fir;_. .1 ✓:4`,,1 ,a'y� ..! v, <br /> Fj <br /> S <br /> 42-02-061 ONSITE WASTEWATER PERMIT <br /> 1212212003 <br />