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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT /� a <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-31O 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 ri 7.,CI�TJY/zlP{ rn <br /> CROSS STREET S APN ) t i l '��/L�U PARCEL SIZE J O p <br /> OWNER NAME T/v PHONE a /Igo <br /> OWNERADDRESS �./Q-WfY CITY/STATE/ZIP <br /> CONTRACTOR ��,dju(AV ^ PHON <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑CA2 -36 OTHER NUMBER ZS§Zi= EXPIRATION DATE 9LWATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DE SI NED/ALTERNATIVE <br /> ❑ REPLACEMENT Ac DESTRUCTION C _ <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE MMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF EDROOMS: NUMBER OF EMPLOYEES: <br /> 1p SEPTIC TANK TYPE/MFG /1-VC CAPACITY gal #OFCOMPARTMENTS C <br /> /❑—GREASE TRAP TYPE/MFG ///---��� CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL P _ ft FOUNDATION R PROPERTY LINE zo ft <br /> CJ LIFT STATION SIZE TYPE OP PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) I I I <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEARESTWELL ft FOUNDATION ft PROPERTY LINE I <br /> Z <br /> FILTER BED WIDTH 'J - 3!5ft LENGTH 32— D ft DEPTH 3 ,s- ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION J(J ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft\�) <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft 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 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 /> I M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNE TITLE OW,94e2Z DATE -ff At <br /> Q IN CLIN TY <br /> . a <br /> N <br /> u <br /> O <br /> re vi <br /> 51- <br /> n <br /> r - <br /> / <br /> — _ - - - EPARTMENT US�ON <br /> Application Accepted Date Area Employee ID# <br /> Final Inspection By / —C9 SPECIAL ERMIT-Approved by �7' <br /> Character of Soil to Depth of 3 Ft: PitlSump Soil Character: <br /> COMMENTS <br /> to V,4S <br /> v, <br /> PE SCReceived Check#/ Amoun[ Permit] <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit IDN <br /> �( 1 Z L C�q 0 X15(72A 05 c <br /> 2 2� '�Sv 2 05 <br /> 42-02001 ONSITE WASTEWATER PERMIT <br /> 1222/2003 <br />