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30 <br /> „ tJ <br /> ONSITE WASTEWAI,,T-)TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT IA 304 E WEBER AYE-3-171,-STOCKTON CA 9- #(209)4611-3420 <br /> NON-REFUNDARLE'7PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS OL Q N� row e-- r'1 CITYIZIP � <br /> CROSSSTREET E�/ +'YPN ��f PARCEL$IZE •� <br /> OWNER NAME bl`ler n C" ` Vi �✓� PHONE N <br /> OWNER ADDRESS CITYISTATEIZIP <br /> CONTRACTOR r PHONE <br /> CONTRACTOR ADDRESS CITYISTATEJZIP <br /> LICENSE U C-42 ❑C-35 OTHER NUMBER ERPIRATION DATE 1� <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFOR14ATION: Coordinates X V f <br /> It PERC TEST # / BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: - CI NEW INSTALLATION ❑ RF.PAIWADDITION ❑ ENGINEER DESIGNED IALTERNATIVE ryry <br /> LI REPLACEMENT - ❑ DESTRUCTION V <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMATERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LME ft <br /> ❑ LIFT STATION Size TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINTS LENGTH OF LINTS ft <br /> DISTANCE TO NEARF.,ST WELL R FOUNDATION R PROPERTY LINE fl <br /> ❑ FILTER BED WmTll ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL A FOUNDATION R PROPERTY LINE R <br /> ❑ MOUNDED WnEr" ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION f1 PROPERTY LINE R <br /> 1 ❑ SUMPS WITH ft LENGTH R DEPTH R <br /> DI.STANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH_A LENGTH ft DEPTH ft <br /> DISTANCE.TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPI'll ft <br /> DISTANCE TO NEAREST WE'LL R FOUNDATION III PROPERTY LINE R <br /> I HEREBY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THE WORK WILL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> C��jl <br /> ORDINA CF.S,STATE LAWS AND RULES AND REGULATIONS OFSAN JOAQUIN COUNTY. <br /> M 24 RAD' E.REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697SIGNED TITLE Irl' IL— DATE 7 <br /> _ I <br /> � ... go <br /> �-TEsT <br /> B d <br /> d <br /> I pBeau <br /> m <br /> d � A <br /> O <br /> 24 <br /> \ I q <br /> \ <br /> \ r <br /> D PARTNIENTU EON 4 <br /> Application Accepteoof3 <br /> - Date V Area Employee ID# <br /> Final Inspection By Date ��x2'✓L�f ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Pit/Sump Soil Character: <br /> COMMENTS � <br /> -i <br /> PE SC Received hec Amount Date Permit/ Invoice# Permit IDN <br /> Code INFO B Cash Rem'ted Service Re uest# <br /> Z1 c <br /> 42-C2-GOI l ONSITE WASTEWATER PERMIT <br /> 12122/2003 <br />