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ONSITE W' is EWATER TREATMENT SY;�EM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL if )OM EPARTMENT 600 c MAIN STREET-STOCKTON CA 95202-(209)468 <br /> NoN-REFUNDAB E E CALL 209 953-7697 FOPINSPEcTioNs EXPIRES 1 YEAR FROM DATE ISSI4 <br /> JOB ADDRESS P4 t=s , CITY/ZIP IDWAZ <br /> CROSS STREEThmmor APN PARCE Sty <br /> 1 <br /> OWNER NAMEWAZVjL HONE <br /> OWNER ADDRESS <br /> A CITY/STATE/ZIP <br /> CONTRACTOR -A. t PHONE — <br /> CONTRACTOR ADDRESS WLLSOW WM CITY/STATE/ZIP ./P <br /> LICENSE X C42 ❑ C-36 OTHER A NUMBER i EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Co rdinates X Y <br /> ❑ PERC TEST # BUQ DING 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 AF EMPLOYEES: <br /> X SEPTIC TANK TYPE/MFG CAPACITY <br /> gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG _ CAPACITY gal #OF COMPARTMENTS I <br /> DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OI.SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES X LEACHING CHAMBE #OF LINES I LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION g PROPERTY LINE it <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH g <br /> DISTANCE TO NEAREST WELL ft. FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LAT ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS Wtom ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PTTS NUMBER WmTa ft <br /> DEPTHItrr- <br /> DISTANCE TO NEAREST WELL Anrit FOUNDATION It PROPERTY LINE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> n/�, <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> �0)j hIdrt,M yj i N ICEREQUIREDFORI lAS-PeL L M)953-7697 7 <br /> SiGNE \�I)�l►]lJ/� �1C/1 TITL T 7 DATE <br /> D <br /> 2 07 <br /> 'au Ag ITAL <br /> TMENT <br /> I <br /> DEPARTMENT E ONLY <br /> Application Accepted Date Area Employee <br /> Final Inspection Date C 13 SPECIAL PERMIT by <br /> by <br /> Character of Soil to of 3 Ft: Pit/Sump Sod Character: <br /> COMMENTS Q(A3 Lj�t <br /> PE SC Received Checldll Amount Date Permit/ Invoice# PerWt ID# <br /> Code INTO B s Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER PERIAT <br /> MM V I <br />