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33 2�5� kascr— <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT Sam ovl L4r ',— <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE - 3" FL - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-769 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />S CTTYaw <br />CROSSSTREET H'W <br />Y 3� APN ���1OD L7 ARCEL SIZE J % <br />e <br />•TJOWNER <br />1 <br />OWNER NAME <br />ADDRESS <br />CITY/STATEIZIP <br />CONTRACTOR <br />L-- PHONE <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE ❑ C-42 <br />❑ C-36 OTHER NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # <br />$UILDING PERMIT # VfO LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION ❑ REPAIR/ADDrrION ❑ ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT ❑ DESTRUCTION <br />INSTALLATION WILL <br />SERVE: C� RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />` <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG CAPACITY Qn_ gal # OFCOMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG CAPACITY gal # OF COMPARTMENTS ((1 <br />11 <br />d <br />❑ PKG TX PLANT <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE R <br />r w <br />v \1 <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />EACHING CHAMBERS to, Y # OF LINES 70 LENGTH OF LINES 2— <br />DISTANCE TO NEAREST WELL �(0 b ft FOUNDATION f—L _ft PROPERTY LINE t() ft <br />DISTANCE <br />❑ FILTER BED <br />WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br />O <br />❑ MOUNDED <br />WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br />SUMPS <br />WIDTH 2. ft LENGTH Z 0 ft DEPTH CJ ft <br />t_ <br />DISTANCE TO NEAREST WELL 15L-0_ ft FOUNDATION 1 0 R PROPERTY LINE U R <br />❑ DISPOSAL PONDS WIDTH ft LENGTH it DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION II PROPERTY LINE R <br />❑ SEEPAGE PITS <br />NUMBER WIDTH R 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 RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MI MUM 2244 HH UR ADVANCE NOTICE REQU1'- ^ -IR INSPECT 'CALL (209) 953-7697 <br />SIGNED <br />fifL .TITLE DATE / <br />SIJ <br />3b' <br />I �y� <br />Io <br />r-, r ( 3° 7S'�i <br />10, <br />DEM [a EET <br />Application Accepted By Date �[�ISPECIIALPERM�ITAppro� <br />Final Inspection By <br />Date � <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />/2 7-05 $ ultl—�f( ft rkeel t!bh'r►o' T LT �Pth t / o <br />n <br />I <br />PE SC <br />Received Cha Amount Date Permit/ Invoice # Permit ID# <br />Code INFO <br />B Cash Remitted Service R uest # <br />�1< SR�o4u5�► <br />�t <br />42.02-001 <br />ONSITE WASTEWATER PERMIT <br />12/222003 <br />