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i <br /> ONSITE WASTEWATE- -REATMENT SYSTEM PERMIT <br /> ;AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3""FL-STOCKTON CA 9520. 19)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> IOB ADDRESS I ! �I 1/d L N L•. F F ` CITY/ZIP <br /> H <br /> :ROSS STREET !`'•C,'+T` l— APN '1 !PARCEL SIZE 2= .�' \ •,,o <br /> OWNER NAME PHONE y <br /> �7 ]E �. ^� <br /> )WNER ADDRESS /_ �I 7` "> \, -�- �• CITY/STATE/ZIP <br /> :ONTRACTOR /(j A PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> NATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # ryUILDING PERMIT# LAND USE APPLICATION# C,-4 <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> '.NSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> I 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 #OFCOMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> i <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> 7 MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ SUMPS WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> 7 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 R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LME ft C <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. I <br /> MINIMUM 24.HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED - TITLE DATE ' '� L <br /> ✓n�nw [ <br /> H EW <br /> FET <br /> a MY <br /> .unr 0 PARCE Y.. i�P�xc[ r G: <br /> H EN.THD A <br /> pqi <br /> n <br /> ,Lb <br /> i <br /> DEPARTMENT USE(NLY <br /> (/ ) y <br /> Application Accepted By �'� I '�`-- Date ]-'Y/G Area r^'/ Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received -•Gheeldt! Amount ate Permit/ Invoice# Permit ID# <br /> Code INFO B Cash „Remitted Service Re uest# <br /> uL2�, 52s � <br /> 42.02.001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />