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fi <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT L <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3'0 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �j f 5 rn <br /> CITY/ZIP <br /> JOB ADDRESS <br /> CROSS STREET ' 1 `" APN l ~I T T 61 <br /> / /PARCEL SIZES �} i�G� O <br /> OWNER NAME UI 1 7�1 1�1� VJ`^"1 � _ PHONE (Y V/[�FT <br /> OWNER ADDRESS 3�nO y ,per ` CITY/,S)TATEIZIP �-" `�- ! " +- t- <br /> L� " I e52a <br /> CONTRACTOR U ' \64L/" PHONE <br /> l <br /> CONTRACTOR ADDRESS CITYISTATEIZIP i <br /> LICENSE Q C-42 ❑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/ADDITIO r ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPC CREASETRAP TYPE/MFG CAPS CIT of©FC REV� <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FoUNDAPeimft MY haVeftemiredIMMOU1 <br /> ❑ LIFT STATION SIZE TYPE OF PUMP work b9r1n gVM� ( dSYSTEM) <br /> [�.... `.9 al Health Division <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #01 Es LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN£ $ <br /> ❑ FILTER BED WIDTH i ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 /> i <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 1 <br /> EPS R ID TH I <br /> DIST E AR LL ft UNDATION ft P PE LINE ft <br /> 1 REBY CERT THA HA P E HI PPLIC ION AND Tit ORK WILL fINCORDANCE IT AN J UIN OUNTY <br /> O INA S, AT AWSA RULES AN O F S COUNT <br /> INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> f <br /> I S 9 <br /> I <br /> MAUI GU <br /> NIR 1`I <br /> H <br /> PARTMENT JJSE ONtY,, <br /> Application Accepted y'. Date �n Area Employee ILA <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 IAmount Date Permit] Invoice# Permit ID# <br /> Code INFO B a Remitted Service Request# <br /> ZI : - 8 -d0 1 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12!2212003 <br /> 9 <br />