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ONSITE WASTEWE 'R TREATMENT SYSTEM PERMIT �a 30 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME, 304 E WEBER AVE-3*D FL-STOCKTON CA -t-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALLii 209 953-7697 FOR INSPECTIONS EXPI�-R''ESAA 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / �0 15-ol 1 44I:T=CC. , � CITY21P RIQ C��q SZ— LA <br /> r� A I <br /> CROSS STREET APN DD/�7 100 '�/i PA//R��CEL � A SIZE . a <br /> OWNER NAME ro��Il' oo S 'I_LLq c O PHONE <br /> OWNER ADDRESS << Of-k�- CITY/STATE/ztP �-�?� <br /> CONTRACTOR PHONE 'ZD C- <br /> CONTRACTOR ADDRESS O CITY/STATE/ZIP `\ <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE S <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X y <br /> PERC TEST # FBUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER < <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS P• <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYsrEM) Q <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. (� <br /> MINIMUM 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE Z o <br /> 'RSWP <br /> xLq <br /> PROPOSED <br /> PARLELI <br /> Af]!'ALLDSf 40.5 KPeS. <br /> OASeI-Intl 4' w_ 1 <br /> n �1P <br /> - - b36.4T <br /> PROPOSED <br /> 00000 M+Aft. <br /> -2!'• PARCEL 2 <br /> PJVMKReb <br /> PARTNCReNIP 0 1]I Keep <br /> I �.�• Iri Ol0'I2Ogb � 1 — - ARI 00}100.0! <br /> •I ]SD.91' ]1369` � P,y vEN+vP.e PARTN?RSNIP <br /> 1 T- <br /> p \ � <br /> SEPTIL PROPOSED <br /> SrSTEn REMAINDER <br /> elrISTIN6 409 KReS f 9)0 1 <br /> Oftsrw,cnne I Pennlnorn '.a <br /> 1 "y _— ca—a�sc�-]004060 ID <br /> 6 IA KRL!• G� <br /> E A O 'M N N <br /> _ T <br /> �S PIFG rtOAO I PMLEL 4 I ..I . <br /> (aexBveo� vac•tow-oemlo <br /> Pi.wGel.! �Nl�S! N.f KRGf• � ll�w\T , <br /> Gen <br /> ,1 ooc•tow-oemlo oocl!•lcwr No. _ __ _ l xcnw / <br /> F 4EPARTMENT USE O�NI v� �J <br /> Application Accep Area Employee ID#,��'_� <br /> Final Inspection yDate S2� GIS ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth o 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS - <br /> 221 1 <br /> I <br /> PE SC ReceivedCheck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Bv Cash- I Remitted Service Request# <br /> V, a <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />