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U, ^d ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER A VE-3""FL-STOCKTON CA 95202 - (209)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697FOR I%SPECT1ONSEXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDRESS Y1� CITY/ZIP I I<fTV( CI <br /> T <br /> CROSS STREET Ls in av tzj APN �`� ^�/ PARCEL SIZE O <br /> OWNERNAME I• tlAl/'17tiL POJI/"•/I PHONE 1/�DS �Y 7� <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR WfAr V&ACVU—ArA-C <br /> CONTRACTOR ADDRESS 12,30CITY/STATE/ZI P <br /> LICENSE C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TA LE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEWINSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: ,�I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG_-1�_�i'� ��PA&Y /fyVTf gal 4OFCOMPARTMENTS <br /> �_ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> LlPKG TX PLANT DISTANCETONEAREST: WELL IJV ft FOUNDATION J�/D ft PROPERTY LINE � it ` <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) 'V <br /> !/ J <br /> I� LEACH LINES ❑ LEACHING CHAMBERS( RAI N v— Mbf LIKES-/n� LENGTH OF LINES <br /> DISTANCF.TO NEAREST WELI-��_R FOUNDATION {V ft PROPERTY LINE {O R IT' <br /> ❑ FILTER BED WIDTH ft LENGTH R DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH R C <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft r-. <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft (�y <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R "` <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 /> MINIMUS U �'OT ICF:REQUIRED FORINSPECTIONS-PLEASE CALL(209)953-7697 J� <br /> SIGNED�`� / TITLE DLLJNjA?- DATE v <br /> aI I lilt ILI L-200 <br /> A J A UI <br /> ]Fj AB M N <br /> � d <br /> T,O <br /> . - -- - -- DEPARTMENT'U O _.— <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By ate _ ❑ SPECIAL PERMIT-Approved by / <br /> Character of Soil to Depth of 3 Ft: Pi ump Soil Character: <br /> COM ENTS <br /> C n �+ <br /> j � M <br /> PE SC Received Check#/ A unt Permit/ - w� <br /> Code INFO B as Remitted Date Service Re .est# Invoice# Permit ID# <br /> a-fl b o io <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />