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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT �^ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E W ERER AVE-3`°FL-STOCKTON CA 95202 -(209)468-3420 <br /> k NON-REFUNDABLE PERMIT t CALL(209(.953-7697 FOR INSPECTIONS EXPIR <br /> ES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS ` F7 �`+, 4r. ?f u--.- V J .:�-��•+ � CITYIZIPCROSS STREET 4k-.-.cs I� APN - <br /> OWNERNAME - �.". k, F� I „ G rn <br /> fl�j F OWNER ADDRESS j CITYISTATE/ZIP <br /> f CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATEIZIP r <br /> { LICENSE 0 C-42 ❑C 3 OTHER NUMBER E%PIRATION DATE <br /> GWATER TABLE DEPTH: Il GEOGRAPHICAL INFORMATION: Coordinates x Y �11 <br /> i <br /> {❑ PERC TEST # ( BUILDING PERMIT# ' LAND USE APPLICATION#eA -/7(sem' ll <br /> TYPE OF WORK: U NEW INSTALLATION LI REPAIRIADOITION Cl ENGINF,ERDESIGNEDIALTERNATtVIE <br /> ❑ REPLACEMENT Cl DESTRUCTION _ <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUM HER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPFJMFG CAPACITY gal #OF COMPARTMENTS `^-- <br /> ❑ GREASE TRAP TVPElMFG CAPACITY gal #OF COMPARTMENTS <br /> O PKG TX PLANT DISTANCE TO NFAREST: WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> t ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> I <br /> DISTANCE TO NEAREST WELL ft FOUNDATION A PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION fl PROPERTY LINE ft <br /> - ❑ MOUNDED WIDTH A LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fi PROPERTY LINE R <br /> ❑ SUMPS WIDTH fl LENGTH R DEPTH ft <br /> DISTANCE T'O NEAREST WELL R FOUNDATION fl PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH fl LENGTH ft DEPTH ft <br /> F. DISTANCE TO NEAREST WELL R FOUNDATION fl PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION fl .PROPERTY LINE R <br /> [HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DON h ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGL LATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUI RED FOR INSPF.CTIOYS-PLEASE CAIA(209)953-7697 �r <br /> SIGNED ��-. ____ __ _ ._ye�_,_.._---- TITLE ~• - 1 r---'�--�"' DATE <br /> I <br /> IN <br /> fj <br /> _ 1 <br /> I! <br /> t <br /> S <br /> L \ <br /> F, '1171 <br /> L! <br /> OQIN <br /> C ' <br /> DEPARTMENT US�ON <br /> Application Accepted B3 111 lY ,c- .f r-, Dafe p Area Employee ID# t I ! <br /> 'F-•_r 4 77 <br /> Final Inspection By Dale ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PLVSump Soil Character: <br /> COMMENTS <br /> T+ PE SC Received (Check## y Amount Permil! <br /> Cade INFO 13ash_ Remitted Date ServlceRequest# Invoice# Permit ID# <br /> L7� <br /> 5".;14 4s.1 <br /> - ..� �11 rlq Jl��iF3y �� <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> I212MD03 <br />