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�y <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE•3'D FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT '-" ' 0091953-7697 FOR jNSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS tJ/O /IT.J—'�` CITY/ZIP / <br /> CROSS STREET 1-4+rrCsr�4L L a AP,�2^7 PARCEL'SI/7.E <br /> ��jj <br /> OWNER NAME //�� PHONE )66©4'30 <br /> OWNER ADDRESS SQI CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATEJZIP <br /> LICENSE ❑C+32 ❑C-36 OTHER 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 ❑ REPAIR/ADDITION ❑ E {NEER DESIGN D/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ HER <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 <br /> ❑ PKC TX PLANT DISTANCETO NEAREST: WELL ft FOUNDATION ft PROPERTY LME ft G <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE_ ft <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH ft 1 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R •` <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft nI <br /> L <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> I 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 RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> ' <br /> MINI Nt 24 HOU DN 'CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 — <br /> SIGNED TITLE erC---yN.A.— DATE c 2EN iAL <br /> 7 'R <br /> I Li- <br /> C U <br /> NV R <br /> i <br /> DEPARTMENT USE ONLY {� � 1 <br /> Application Accepted By Date J Area Employee ID# !!!! <br /> Final Inspection Date /CY ❑ SPECIAL PERMIT-Approved by <br /> Character of Soll of 3 a PiUSump Soil Character <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service R nest# <br /> 22 ) L 5 bScqq <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12(22!2003 <br />