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301>> <br /> SYEM PERMIT <br /> ONSITE WA/jEWATER TREATMENT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL FIEALTF.,VEPARTMENT 304 E WEBEr<-ivF -3'0 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 Folz INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> J08 ADDRESS J CITYIZIP �R' ? { y <br /> ^ �' ) PARCEL SIZE 1,.F .1 C <br /> CROSS STREET L�� -�J APN p <br /> A <br /> OWNER NAME V <br /> PHONE <br /> CITY/STATE/ZIP �i1111�M1 5 � — <br /> OWNERADDRESS 4 * r., <br /> CONTRACTOR <br /> 1 <br /> CITYISTATEIZIP 1 <br /> CONTRACTOR ADDRESS <br /> LICENSE ❑C-42 ❑C-36 OTHER <br /> NUMBER EXPIRATION DATE <br /> ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> WATER TABLE DEPTH: <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> L7 REPLACEMENT Q DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Nt1MBEROF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPF/MFG CAPACITY gal #OF COMPARTMENTS .O <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL fl FOUNDATION ft PROPERTY LINE ft- <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> El LEACH LINES LI LEACHING CHAMBERS #OF LINES LENGTx OF LINES �. <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> 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 ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft 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 q <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft.'4� <br /> r DISTANCE TO NEAREST WELL. ft FOUNDATION fl PROPERTY LINE <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 JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS--PLEASE CALL(209)953.7697 r <br /> SIGNED TITLE �� DATE ~�� <br /> 110 <br /> 14 <br /> x I U1 G <br /> 4R P1 <br /> DEPARTMENT SE O LY <br /> Application Accepted By Date l I v Area f Employee ID# �' <br /> Final Inspection By Date ❑ SPECIAL PER 41T-Approved by <br /> Character of Soil to D of 3 F 10,PitlSump Soil Character: <br /> COMMENTS <br /> rat A <br /> Q - . AQ <br /> PE SC Re elved Check P mit/ <br /> Code INFO B ash Date Service Request# Invoice# Permit ID# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12122/2003 <br />