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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3R"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> Job ADDRESS <br /> �� CITY/ZIP T :3 <br /> CROSS STREET .G .r,.s% APN Qy!-j[n-q 0 PARCEL SIZE ` �p <br /> OWNER NAME PHONE <br /> OWNER ADDRESS 3_071 /1 6 ISTATE/ZIP :7Z/ s/ "1 5-3:76, <br /> CONTRACTOR '3 �7 <br /> PHONE C� <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP .-4 4c.• <br /> LICENSE C-42 ❑C-36 OTHER NUMBEREXPIRATION DATE <br /> WATER TABLE DEPTH:— ft GEOGRAPHICAL INFORMATION: Coordinates x Y_ <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION#� <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEERO SIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE Q COMMERCIAL ❑ OTHER_ <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG .+ CAPACITY gal 4 OF COMPARTMENTS <br /> ❑ CREASE TRAP TYPE/MFG CAPACITY ^� gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION �7 Ft PROPERTY LINE ti <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES�� � ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION �J� �� ft PROPERTY LINE_ %�� ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ti <br /> DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE it <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ti PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ti <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL _ft FOUNDATIJN tt PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH _ tt DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft 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 ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. 1> <br /> INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE A ./� DATE — <br /> ! <br /> S i <br /> 2' <br /> CFI AIT <br /> " ES <br /> N%Fi -1 1 <br /> DEPA RTMEN7 U ONLY <br /> Application Accepted By Date O Area Employee[D#{ C <br /> Final Inspection Byea e Cd © SPECIAL PERMIT-Approved by T <br /> Character of Soil to Ud5th of 3 Ft- Pit Sump Soil Character: <br /> COMMENTS <br /> PE SC Received hec Amount D e Permit/ Invoice# PermitlD# <br /> Cade INFO ash Remitted Service Request# <br /> SRuo <br /> 42-01-001 <br /> 12/2/02 ONSITE WASTEWATER PERMIT <br /> V - <br />