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ONSITE WAST'WATER TREATMENT SYST 4PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L�.tTMENT 304 E WEBER AY-3"'FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT <br /> JOB ADDRESS CALL(209)953-7697 FOR INSPECTIONS y}EXPIRES I YEAR/F/R�OM DATE ISSU D <br /> CITY/ZIP ✓� ' <br /> , <br /> APN nos � —T� PARCEL SIZE '-i e <br /> CROSS STREET <br /> OWNER NAME _ <br /> / � <br /> 4 17 r L S � PHONE <br /> OWNER ADDRESS W4 / P-E` 1 l � 0A' CITY/STATE/ZIP f d <br /> T�C 3 <br /> CONTRACTOR M U� PSH rO�NJEJ <br /> CONTRACTOR ADDRESS ?,?- /Jv'� r CITY/STATE/ZIP / 5 2-42- <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER r EXPIRATION DATE 13 o ) Jeyww <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> k3) <br /> PERC TEST(S) NUMBER LAND USE APPLICATION# <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 /> ❑ 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 ti FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tt <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH R <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 /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH tt <br /> DISTANCE TO NEAREST WELL R FOUNDATION tt PROPERTY LINE R <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tt <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREP11 ARED HIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> ATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> UM 2 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE: PEnG " fAL <br /> DATE �c>3 <br /> . . <br /> ROAD <br /> KGOWAY <br /> "--- <br /> T_ AV vrn-RAMP <br /> 4' /' 4'/ /" a05 t U <br /> ` J <br /> M <br /> HIGHWAY 99 <br /> ... <br /> `J"�^��1f y`�} DEPARTMENT USE ONLYOw /�� <br /> Application Accepted By M('G Date 1 0 Area Z �-- Employee ID# <br /> Final Inspection By Date / �Q3 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: t/Sump Soil Character: <br /> COMMENTS <br /> cn- � m_� � A />r / ,r_�� � o o� moi• o� <br /> - <br /> PE SC Recei _ Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> �-zzz s�i 7 y-7 <br /> 42-01-001 `T�1". cS�j�leJ/�"'%' l�/,lil.Zz��/,...tLet�Ls-1�/L[.L�"'�E�G��./�G' �/1,2Z✓``9� c �� l /4t/d4� �/3g/� <br /> 12/2/02 ONSITE A <br />