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ONSITE WASTE`ATER TREATMENT SYSTEIV PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA?._.ENT 304 E WEBER AVE , FL-STOCKTON 0 - 420 <br /> NON-REFUNDABLE PERMIT ^ ^CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE SSUED <br /> JOB ADDRESS �I /1 L/ ► CITY/ZIP R/FSO/1I !ZS-337 <br /> CROSS STREET /� <br /> rnY'I �V1,y� � PARCEL SIZE Zr/. 4-5 � <br /> OWNER NAME � L �]C ,OF>I�7/•� t/b� rI �� PHONE J 15-" ¢ZCJ� <br /> OWNER ADDRESS r• i G1 V xC J y CITY/STATE/ZIP_ �OI��S 76 2:3 .!573 <br /> CONTRACTOR il, L j/IV PHONE � �i`4 0 <br /> CONTRACIY)H ADDRESS 7"yy��' O 80X l —,7 24 CITY/STATE/ZIP _ �`JC� 9 3 IR <br /> LICENSE ❑C-42 ❑C-36 01111[R NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: fl GEOGRAPHICAL INFORMATION: Coordinates X - Y <br /> PERC TEST(S) NUMBER LAND USE APPLICATION# 'y <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 UNTI:S: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SI?PTIC TANK TYI,IS/MF(i CAPACITY _ gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPOMFO _ __ _ 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 R PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ MOUNDED WIDTH 11 LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <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 ft DEPTH 1t <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tt <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH 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 JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> Uhl 24 HOUR ADVANCE:NOTICE:REQUIRED FOR INSPECTIONS-PLF.ASF.CALL(209)953-7697 <br /> SIGNED ^{ TITLE DATE, <br /> LIL- <br /> jC[AC)IJIN CO N <br /> NV RO <br /> c FH III FI-T4 AQT— <br /> so <br /> L on <br /> -477 <br /> 41F--- <br /> DEPARTMENT USE O 'LY <br /> Application Accepted By — Date Area _ Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil t pth t: Pit/Sump Soil Character: <br /> COMMENTS _ - <br /> PE SC Received heck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> 42-01-001 ONSITE WASTEWATER PERMIT <br /> 12,1 W <br />