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ONSITE WA, EWATER TREATMENT SYS' M PERMfiCANNED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER} E -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL, 209 953-7497 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> S <br /> JOB ADDRESS CITvfZrP / —y <br /> CROSS STREET APN 16AS /111�7 r J� PARCEL SIZE/?-0v <br /> ^7 �j <br /> OWNERNAME PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR .!i PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION Eff REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT G DESTRUCTION i(/, O <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: l NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> P121 G SEPTIC TANK TYPE/MFG . CAPACITY ©� gal #OF COMPARTMENTS <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 ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 fe 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 ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOA-QUIN COUNTY <br /> ORDINANCES,STATE LAWS AiND'RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 OUR ADV CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> Lo <br /> i <br /> I <br /> I 3 <br /> yr Q N <br /> 01) : -"�I � itTMENT'1�5E' LY--�Date Area Employee ID#tion cceFinal Inspection Date f�j� ❑ SPECIAL PERMIT.-Approved by <br /> Character of Soil Pit/Sump Soil Character: <br /> COMMENTS &2L o LQr aE gEaFP :KXA <br /> PE SC Received kQecMAmount Permit! <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> Cl 1P <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12!2212003 <br />