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pID ONSITE WAS WATER TREATMENT SYS" M PERmiSCANNED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D.:PARTMENT 304 E WEBER Ami r; -3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT ,1 �/ CALL �2t0�9® 953-7697 FOR INSPECTIONS EX�P/IREES�r1�YEAR FROM DATE ISSUED <br /> sc <br /> JOB ADDRESS lig,60®/257A f -r/' ZO"A Y 42® �/ G CITY/ZIP �A A T9h+ <br /> CROSS STREET A«.a`J'-r®N" � oA p APN L—D " t J `' y PARCEL SIZE ` ` O <br /> � v <br /> OWNER NAME <br /> � � G- -� i PHONE 3 <br /> OWNER ADDRESS l` ' ) /� / CITY/STATE/ZIP <br /> CONTRACTOR 4 PHONE O <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP Q 3 <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# n <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 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 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 /> 't <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH 111 <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 /> Iv <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft 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 /> I HEREBY C TIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> 64ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> L 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE ®h/A,�rlc- DATE Ap-3 0 04 <br /> A <br /> � 5 <br /> \4.11 <br /> _>w <br /> DEPARTMENT USE NLY SAN JU�'�" AENTAL <br /> G, 6 EIIVIRONM <br /> Application Accepte*of <br /> L_ Date Area � F{D � <br /> Final Inspection By > Date 3 ❑ SPECIAL�ERMIT-Approved by j <br /> Character of Soil to Pit/Sump Soil Character: <br /> COMMENTS <br /> J � J c1�� <br /> 166-57 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By as 1 Remitted Service Request# <br /> 19WID 00 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />