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. <br /> l ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3M0 FL-.STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS ADD-?oD(a- yl �/o xz- CITY/ZIP VG <br /> / 1 J//LJ � <br /> CROSS STREET C err 6I 'fa n APN& / ��� � PARCEL SIZE -2,1 ,qC <br /> 0 <br /> OWNERNAME 10Y PHONE � <br /> Q <br /> OWNER ADDRESS Sa....t� CITY/STATE/ZIP <br /> CONTRACTOR I C `7 O Scf iA C (-- PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP o C $ <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> LPERC TEST # BUILDING PERMIT#, -V AND USE APPLICATION#_ _ <br /> TYPE OF WORK: New INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: LBI<ESIDFNCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: �1 NUMBER OF EMPLOYEES: 11 <br /> SEPTIC TANK TYPE/MFG��`� CAPACITY 2-Dne, - gal #OFCOMPARTMENTS pc- <br /> ❑ CREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS ( �1 <br /> I R �J� <br /> ❑ PKG TX PLANT DISTANCE TO NF.ARES`T: WELL� fl <br /> 5-, - <br /> ft FOUNDATION (� S PROPERTY LINE O <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I <br /> LEACH LINES WILEACIIIING CHAMBERS �y #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL fl FOUNDATION_IQ ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft q� <br /> DISTANCE;TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE <br /> 1)- <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH _ ft <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 R PROPERTY LINE ft <br /> 0 SEEPAGE PITS NCMBER WIDTH ft DEPTH ft /Z&. <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 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 /> �'�Jp VII IMUM 24 HOAR ADVANCE NOTICE REQUIRED FOR INSPECTTIONS-'P^LEASE CALL(209)95;-7697 <br /> SIGNED TITLE -Ori 0^Y QC-d(a'r DATE <br /> i <br /> IiI <br /> Tz <br /> 17 <br /> r <br /> CO NT <br /> DF:PART.MENT SE ON ,l' -�tNDEPA I / <br /> Application Accepted By - Date Area Employee ID# <br /> Final Inspection By '�l Date j -'LL`Z_� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept of 3 Ft- it/Sump Sol rPcter: <br /> COMMENTS <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Request# <br /> /2C) C)q 'Z,I r <br /> 42.02.001 ONSITE WASTEWATER PERMI'l <br /> 12/222003 <br />