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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT t J' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFU IT C L(20U953;4EWFOR INSPECTION EXPIRES TE ISSUED i <br /> JOB ADDRESS - Crry/ZJP <br /> CROSS STRE APN L PARCEL SIZE d rtol <br /> 173 2, <br /> OWNER NAME PHONE <br /> OWNER ADDRESS CITY/STATER <br /> M' PHONE <br /> �o <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS I f)COw CrrY/STATE21P <br /> LICENSE ? •.42 ❑C-36 OTHER / NUMBER�ffffj EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 3 PERC TEST # BUILDING PERMIT# �O ��LAND USE APPLICATION# <br /> TYPE OF WORK: G NEW INSTALLATION G REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> D REPLACEMENT 1 11O DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCECOMMERC' L ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF EDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG �� CAPACITY <br /> gal #OF COMPARTMENTS <br /> Q GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL It FOUNDATION E3 It PROPERTY LINE —50 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES IVLEACHING CHAMBERSE5W #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It v` <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It N <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 /> O SUMPS WIDTH ft LENGTH It DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R T^- <br /> ❑ DISPOSAL PONDS WIoTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft C <br /> ❑ SEEPAGE PITS NUMBER WIoTH____ __ ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION H PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I 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. �/J <br /> SIGNED Mt IMUb N CE REQUITITLE <br /> RED FOR I P MY 09)953-7697DATE I 3 rO ? <br /> I <br /> Or r <br /> AfA <br /> FN <br /> �I <br /> 6 <br /> E <br /> } <br /> I— I <br /> IR N <br /> E <br /> I <br /> 1 � <br /> 1 1 <br /> DEPARTMENT US OILY 3 <br /> Application AccepteJl }y Date Area Employee ID#=37 q g G <br /> Final Inspection B�_ Date El SPECIAL PERMIT-Approved by <br /> Character of SolI to Depth of 3 t: Sump Sal Character: <br /> COMMENTS CIL.D "-r aF Ft 11 Ec�eF�So2 �6 rO �GEe S • �u6ue ee/E�e— <br /> I Sy �J c—I TE . S S htvl coni m /J. 6 Tv �t)vE <br /> PE SC ReFelved Ch Amo nt Date Invoice# Permit ID# <br /> Code INFO ash Remitted Service Re uest# <br /> 423 f 531 / /oV . �' 7 <br />