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f <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTit DLPARTMENT 304 E WEBER AVE-3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-1697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOBADDRESS 11x,4,e9 CITYI"L1P <br /> I <br /> In <br /> CROSS STREET +_`i ApN O '�+LJ O PARCEL SIZE o <br /> OWNER NAME �T t t- PHONE Zi } !j 1- - <br /> OWNERADDRESS CITYISTATFJZIP 1 <br /> CONTRACTOR © PHONE to �• <br /> CONTRACTOR ADDRESS CITYISTATFIZIP <br /> 94, <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE .� <br /> r WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# -� <br /> TYPE OF WORK: ❑ NEW INSTALLATION I3 REPAIR/ADDITION Q ENCINEERDESICNEDIALTERNATIVF. <br /> ❑ REPLACEMENT ❑ DE$FRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES; <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPF/MFG CAPACITY gel 9 O COMPARTMENTS <br /> ❑ PKC TX PLANT DIWANCETO NEAREST: FELL A FOifNDATION 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 R <br /> DfSTANCETO NEAREST WELL R FOUNDATION R PROPERTY LINE () <br /> ❑ FILTER BET) WIDTH ft LENGTH R DEPTH R <br /> D[SFANCETONEARFSF WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH fl DEPTH <br /> DI STANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH fl DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE. ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH R <br /> -10 <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft <br /> DISTANCFTONEAREST WELL__ ft FOUNDATION R PROPERTY LINE R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQU[N COUNTY. t� <br /> I' MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- LEASE CALL(209)953-7697 <br /> SIGNED TITLE <br /> DATE <br /> ITO <br /> a <br /> 5N <br /> O AL <br /> L <br /> r <br /> ti 1 -4 <br /> L-� I =T-T 9;1 fl <br /> __. _ ..,.... . ...DEPARTMENT SE LY <br /> Application Accepted HY Dale Arca Employee IDN <br /> Final Inspection By - DQ SPECIAL PERMIT-Approved 8y <br /> Character of Soil to Dept 1`317t: PiLfSump Soil Character: <br /> COMMENTS "�ZG _ z - Sic/, tc:' �CrJGi=� t`� <br /> C, <br /> r PE SC Received Check#! Amount Date PermiU Invoice# Permit IDR <br /> i Code [NFO 6 as Remitted Service Renuesi# <br /> 2 1-a ,6 / 79--w0:1,D 4Zpo u 25. <br /> 4212201 <br /> I2122 <br /> Q+zo03 ONSITE WASTEWATER PERMIT <br />