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II. e <br /> ONSITE WAST' WATER TREATMENT SYS7 M PERMIT zl <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH i TMENT 304 E WEBER AV_ 3 FL-STOCKTON CA 95202 - (2 4 4�3420 1 <br /> NON-REFUNDABLE PERMIT , :CALL(209)953-7697 FOR INSPECTIONS "EXPIRES I YEAR FROM DATE IFSlj,, <br /> JOB ADDRESS v , CITY/ZIP Al 4+ <br /> CROSS$TAFFY APN -moo —D`G�' —�L PARCEL-SIZE z <br /> OWNER NAME S PHONE <br /> !A y <br /> OWNER ADDRESS � CITY/STATE/ZIP <br /> CONTRACTOR = � ONE j/P <br /> CONTRACTOR ADDRESS <br /> CITY/STATE/Z[P! <br /> LICENSEC-42 ❑C-36 OTHER.' NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH:�D��! r'.I. ft GEOGRAPHICAL INFORMATION: Coordinates X €� . Y <br /> ❑ PERC TEST(S) NUM ER LAND USE APPLECAT[ON# <br /> TYPE OF WORK: a NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑''• REPLACEMENT - ❑ 'DESTRUCTION <br /> INSTALLATION WILL SERVE: (RESIDENCE' , ❑ COMMERCIAL j © OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: J.1 NUMBER OF EMPLOYEES: <br /> II ,q <br /> SEPTIC TANK TYPE/MFG�(J]`� SCJI� CAPACITY 1 k2w i gal #OFCOMPARTMENTS <br /> _—_ <br /> ❑ GREASE TRAP TYPE/MFG !f CAPACITY gal #OF COMPARTMENTS <br /> 0 PKC TX PLANT DISTANCE TO NEAREST: WELL ADO ft FOUNDATION I ft PROPERTY LINE 40 _f ft ! <br /> ❑ LIFT STATION SIZE TYPE OF PUMP" ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ;Y LEACHING CHAMBERS *}t4-..#OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST. WELL � � ft FOUNDATION, PROPERTY L[NE "1�0 ft <br /> ❑ FILTER BED WIDTH �� ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 MOUNDED WIDTH I� ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH IM ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R L� <br /> ❑ DISPOSAL PONDS WIDTH ft 'LENGTH ft DEPTH R Cry? <br /> DISTANCE ToNEARESTWELL ft FOUNDATION ft PROPERTY LINE ft v <br /> ❑ SEEPAGE PITS WIDTH !! ft LENGTH ft DEPTH ft V <br /> ,w <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft. <br /> �. 4s <br /> HEREBY CERTIFY THAT I HAVE PREPAREDITHIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,` <br /> STATE WS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. t <br /> IN 24 !Ih A VA�}NCCEEjNO,TICE REQUIRED FOR INSPECTIONS-PLEASIE CALL(209)953-7697 t� /1 <br /> SIGNE i� �C r V"y TITLE I DATE [ ~v <br /> ,I II s <br /> i <br /> .f <br /> 011 <br /> G �1 <br /> F7 I <br /> I—Home <br /> fl <br /> I <br /> �I <br /> EI <br /> r <br /> E 1 41 lull, 4- <br /> EI <br /> I <br /> M 0 <br /> A 70, <br /> Vl A M <br /> r <br /> -Applieation Ac-_' " ' `- . � �rDate "CArea ' Employee 1D# <br /> �� • <br /> Finalln5ject n DAte y 54 SPECIAL PERMIT-App db <br /> Character of Soil to Dept of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS Of 6t e & 'd td- D21a l3 } <br /> PE SC Received AmounT Date Permit/ i Invoice# Permit ID# <br /> Code INFO B -1-.s hi Remitted Service Request# <br /> 2. 13 !f-'7 <br /> 42-01-001 ONSITE WASTEWATER PERMIT <br /> 12/2102 <br />