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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT y <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"°FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(2094953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSf�< eV CRY/ZIP C "1 <br /> n CT <br /> CROSS STREET 7V �I S S __ APN D Z` D�'0 Z PARCEL SIZE Jt•S Q( pv <br /> OWNER NAME Aumti CLI TPHONE <br /> OWNERADDRESS c21 S( /!� (���{^� .. •CITYISTATEMP -AC)C , •. <br /> CONTRACTOR "41 e PHONE <br /> CONTRACTOR ADDRESS CITY/STATEJZIP <br /> I <br /> LICENSE ❑C-42 ❑C-36 OTHER - NUMBER EX%RATION DATE <br /> I WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST k BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: �❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT / PbIRUCTN)N i <br /> INSTALLATION WILL SERVE:. ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER ! <br /> NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> Al"SEPTIC TANK TYPEIMFG CAPACITY Bal #OF COMPARTMENTS <br /> ❑ GREASE TRAP •t TYPE/MFG T - ' CAPACITY 'gal #OF COMPARTMENTS -I, <br /> ❑ PKC Ti PLANT DISTANCE TO NEAREST; WELL flFOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE T TYPE OF PUMP ❑ ;SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ EACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R <br /> DISTANCE TO NEAREST+ -WELL ft FOUNDATION R PROPERTY LINE <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION fl PROPERTY LINE - fl <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH fl <br /> DISTANCE TO NEAREST - WELL ft FOUNDATION ft PROPERTY LME fl <br /> ❑ SUMPS WIDTH ft LENGTH ft 'DEPTH fl <br /> DISTANCE.TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R I DEPTH ft <br /> DISTANCE TO NEAREST' WELL ft FOUNDATION ...ft PROPERTY LME n R <br /> 0 SEEPAGE PITS NUMBER WIDTH R -DEPTH 4 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LME R <br /> 0 <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> iORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY.- <br /> . M NI HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-P EASE CALL(209)953-7697 <br /> SIGNED <br /> TI ✓tt DATE J-�V�2 <br /> II. <br /> f <br /> IN 00 1 <br /> r' E VI O <br /> I <br /> 1 <br /> I <br /> 4 <br /> 7EPARTME!Application Accepted Date 3 3D Area " Employee ID#�— 9/ <br /> Final Inspection B Date 13 SPECIAL PERMIT-Approved by <br /> Character of Sall to pth of 3 t: PiUSump Soil Character: <br /> COMMENTS <br /> PE SC Received hecldlr Amount PermiU <br /> Code INFO B Remitted "Date• Service Request# Invoice# Permit ID# <br /> q-7-_21 O—1-V 0 /oo•InJ S 5 I <br /> .s <br /> 42-02-001 - -• - - - - ONSITE WASTEWATER PERMIT <br /> I` 12/22/2003 i <br />