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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3""FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDAB4EP 1�1:VV/ (�7__CAL (20 191553-7697 r• R INSPECTIONS EXP)RE$1 YEAR FROND DATE 155UED <br /> JOB ADDRESS <br /> O✓V D - ra ..ire C1)ITY/CZIIP l7 <br /> CROSS STREET APN ^"'� 5, PARCELSIZE 3-51+015 <br /> OWNER NAME D . <br /> d <br /> �"cc icI �inin <br /> r� r��/� 1`PHONE <br /> OWNERADDRESS "'-`� �L.�7 y�yy 4"`c' CITY/STATE/ZIP 1�`-���,(}" / ,��A 9 ,Zlq <br /> CONTRACTOR ���`'''JJ2JJJ''' ' • "�•{/ �`�}—""- y Ally <br /> "S PHON{E `"��C -`/;2f +/'��� )7 1� ' <br /> CONTRACTORADDRESS %� 106011 0✓ 1 7 CITY/STATFJZIP Ltd' I `�-{ 1 *5, 1" <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE .� <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST(S) NUMBER LAND USE APPLICATION# - t. <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITIoN ❑ ENGINEERDESIGNED/ALTERNATIVE Imo^ <br /> ❑ REPLACEMENT ❑ DESTRUCTION v <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: . <br /> ❑ SEPTICTANK TYPEIMFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE To NEAREST: WELL ft FOUNDATION ft PROPERTY LINE' ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑. LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES It <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION- ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL $ FOUNDATION ft PROPERTY LINE R <br /> Cl SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETO 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 <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERT AT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> U 24 HOUR ADVANCE NOTICE REQUIRED FOR INS/PQ�i PLE/1tSALL(209)953-7697 <br /> SIGNED TITLE CJ``�'C /v DATE (P p <br /> • ' - �-105.5' 60, - — <br /> 171.4' <br /> N c9 <br /> Cal <br /> 467 411.36' 59' <br /> E <br /> pAY1\A1o <br /> s L772.1' D � T rVaj <br /> l / PARTMENT USE -,L f/ <br /> Application Accepted By C,'O Date s A,,Area Employee ID# Q/7 <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Che /' Amount Date Permit/ Invoice# - PermitlD# <br /> Code INFO By, Cash Remitted Service Re uest#.- <br /> 42-01-001 <br /> 12/2/02 ONSITE WASTEWATER PERMIT <br />