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12-', 30ONSITE WASTI ATER 'TREATMENT SYSTE 'P,�ERMIT �o? 00 <br />SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE- -*FL- STOCKTON CA 9520. 9)468-3420 <br />NON-REFUNDABLE CALL (209 7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM'ff<TE ISSUED <br />/PERMIT <br />Q O <br />JOB ADDRESS! CITYIZIP up <br />m <br />CROSS STREET APN O �Z-�� �''EiaP RCEL SIZE <br />t <br />OWNER NAMEO s 5 r PHONE <br />m <br />U <br />OWNER ADDRESS CITY/STATFIZIP <br />CONTRACTOR PHONE ID -77 <br />CONTRACTOR ADDRESS CITYISTATElZIP <br />LICENSE ❑ C42 ❑ C-36 OTHER NUMBER EX D <br />WATER TABLE DEPTH, ft GEOGRAPHICAL INFORMATION: Coordinates X <br />i PERC TEST # BUILDING PERMIT # LAND USE APPLICATION N <br />TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED 1ALT ATIVE <br />Q REPLACEMENT ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: Y <br />O <br />❑ SEPTIC TANK TYPEIMFG CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPFJMFG CAPACITY gal # OF COMPARTMENTS <br />[] PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LIN£ R {{1 <br />`1 y11 <br />• LIFT STATION SIZE TYPE OP Pi1MP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES Q LEACHING CHAMBERS # GF LINES LENGTH OF LINES It �+ <br />DrSTANCE To NEAREST WELL R FOUNDATION fl PROPERTY LINE ft <br />❑ FILTER BED WIDTH ft LENGTH fl DEPTH R <br />DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE fl <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH fl <br />DiSTANCETO NEAREST WELL R FOUNDATION fl PROPERTY LINE ft <br />❑ SUMPS WIDTH ft LENGTH R DEPTH fl <br />DISTANCE TO NEAREST WELL _fl FOUNDATION fl PROPERTY LINE fl , <br />❑ DISPOSAL PONDS WIDTH ft L GTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION A PROPERTY LINE ft <br />❑ SEEPAGE PITS NUMBER - WIDTH ft DEPTH ft <br />DISTANCETONEAREST WELL R FOUNDATION R PROPERTY LINE ft <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THF. WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br />ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />! — Q-1,-5DATE <br />SIGNED TITLE <br />i <br />9 <br />o ra 4 0 <br />ao <br />TV P <br />!. n ° <br />O- DNINE <br />t} <br />b ARTMENT USE NLY _ <br />Application Accepted Date v d f Area y� Employee Sb# <br />Final inspection By a4 7, f ly,5 ❑SPECIAL PERMIT - Approved by 9 <br />Character of Soil tU Plh o 3 Ft; irlSomp Soil Character: <br />COMMENTS <br />PE SC ReceivedCheck# Amount Date Permit/ invoice # Permit 11D#Code <br />INFO B ash Remitted Service Re Dest # <br />q7-) <br />a-rYcr�ra✓ a ..-yyLrV <br />l; <br />42-02-001 ONSITE WASTEWATER PEQI <br />2-02-001 6C�m ..� ��r � <br />