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ONSITE W WATER TREATMENT SYS'_ `'M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 304 E WEBER`"t -34"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL((209)953-769.FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Ci�I•L� ^-' CITY/ZIP n�� - �Z. Lo <br /> =1 <br /> CROSS STREET ? APN 00:5— 0 CLQ-2�J PARC/EL SIZE �( p <br /> OWNER NAME gl4y N ! //"/�L-�y / �I PHONE qCgj 1v//� ^ Irt3QO m <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR l.� GC�'Y y+�7l\ /�P PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-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: Cl NEW INSTALLATION ❑ REPAIR/ADDITION Cl ENGINEER DESIGNED/ALTERNATIVE <br /> L3 REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCETO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES it <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R P <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH it 0 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LME it �Q <br /> ❑ SUMPS WIDTH it LENGTH R DEPTH ft G <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft m <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R f I1 <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STA LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR 4 NOTICE REQUIRED FOR INSPECTIONIS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE ^4 DATE ❑- Q <br /> Vy <br /> rr <br /> h •( <br /> • DEPARTMENT US NL ! (y <br /> Application Accepted By Date _34_1V11!4Area --2 Employee[D# <br /> Final Inspection By �I[ nn i Date ❑ SPECIAL PERMIT-Approved by 9t, <br /> Character of Soil to Depth o 3 Ft: d Pit/Sump Soil Character: <br /> COMMENTSr <br /> et�J 0 pe c <br /> w;i 6yas hece 6,;&d (20M Vain wr <br /> PE SC Received c Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> Lf2.7A C7"25 0 00 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />