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ONSITE WASTEWATER TPEATMENT SYSTEM PERMIT <br /> AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT L 304E WEBER AVE-30.0 FL-STOCKTON CA 95202-(209)x' '•O <br /> amwAON-REFUNDABLE PERMIT CALL(209)95y 7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE hilililliD <br /> _ c I <br /> JOB ADDRESS 7-7 r `� L L �'� �) �" `I CITY/ZIP •'�C.1 T <br /> rr �! <br /> :ROSS STREET V-� f- --� K �� �1 .-• AYN V `! 14-1 -''tEl PARCEL SIZE pO ' <br /> �aa)WNER NAME I� l' 'v n <-- y PHONE ��"1 -'y L(;. 7 1 <br /> OWNERADDRESS r-y�' �- "-� it�." d� F� •�3. 1�. ;.}: CITY/STATEIZIPy+t•• i int (� /!-d' <br /> .ONTRACTOR <br /> PHONE <br /> I <br /> I <br /> —;ONTRACFOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> VATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# TA -.. -F--- -2-I- <br /> B00FYPE 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 /> w-] SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ZI PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE R <br /> 7 LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> wast <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 7 FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> INS DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R ) <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> 1w DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <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 R DEPTH ft -. <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> was <br /> 1 HEREBY CERTIFY THAT 1 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 JOAQUIN COUNTY. - <br /> MINIMUM 24 HOUR-AD%'ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 `• <br /> 1 .' <br /> SIGNED - - TITLE ...1`,� ��'" DATE (c• C'7— <br /> . ......,... +waw.. 1 <br /> I <br /> V a � <br /> o r <br /> JC AC i1r,COUP TY <br /> 1MEN A <br /> VtE-Tr <br /> PLo7 PCOM _ b <br /> (✓' _/1,� DEPARTMENT 9SE ONLY <br /> Application Accepted By `- t/./loll/�/e���"' Date F/LSA Area Employee ID# 3 L(a <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SCReceived Check#/ Amount Date Permitl Invoice# Permit ID# <br /> Code Mtro B Cash Remitted Service Request# <br /> Y1.sz Szr 'L� 7l 73.ru �l :Iv `!Z1r-1 (o <br /> • i <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br /> 6 <br />