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6 <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"FL-STOCKTON CA 95202-(209) 20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEARFROM DATE ISSUED ISSUED <br /> JOB ADDRESS S• / CITY/ZIP c-a-C.-�-1 �l J 3 c)-q y <br /> J p N <br /> ?.39-140- I O PARCEL SIZE <br /> CROSS STREET Q 1 In "- APN / (� Q�/ C <br /> OWNER NAME / m —r O� I�. PHON4 �-o9�O�J�q-�e (Od <br /> OWNER ADDRESS 21D 5 2 S' L (` `1 CITY/STATE/ZIP L V'06-! .4 L 0 l 5 3 Q I <br /> CONTRACTOR tI PHONE 1 l <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTI4ER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION yL REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: CA RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 1 NUMBER OF EMPLOYEES: O <br /> �• SEPTICTANK TYPE/MFG GO IV C- CAPACITY CAPACITY 1 .00 gal #OFCOMPARTMENTS_1 <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS_ #OF LINES I LENGTH OF LINES C ft <br /> DISTANCE TO NEAREST WELL I ft FOUNDATION R PROPERTY LINE R N <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH fl DEPTH ft N <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH ft <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 ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 RUL cr.,..�••^•- ... .... .. wrn.iury <br /> INIMUM 24.HOIA AIIVANCE <br /> SIGNED b i I• (p •��_ C$r <br /> opa <br /> o. <br /> do �h c <br /> C4 wrw <br /> aMv <br /> r...• h <br /> Application Accepted BCLIL— <br /> _...__.. Date GS Area Employee ID# 4 000 s9/ <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PiUSump Soil Character. <br /> COMMENTS AjC- L-ow vr- ez -oerj ��M-R-3-74'1. P-E-adA-C.,—& LQ-4-C.H LICE ui/tt[f( <br /> L%;t'Lt L dJ rS E --TOO C L..OS E 'TG /} <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B u! Remitted Service R uest# <br /> 42.it) IIS T+C 0 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />