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a <br /> r <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT _ CALL 209 953-7697 FOR INSPECTIONS EXPIR&§ 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS C?1 1 y 2_ clfTv<z[P <br /> APN I I � o <br /> CROSS STREET - PARCEL SIZE / p <br /> OWNER NAME 'V (� j PHONE // ✓� <br /> � <br /> OWNER ADDRESS CITYISTATEIZIP 1 <br /> � F <br /> CONTRACTOR PHONE <br /> 1 <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPH[CAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK:, ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNEII IALTE$ TIVE <br /> ❑ REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LfVINC UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK -TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS R <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP �JHTAN� I L SED SYSTEM) CD <br /> ❑ LEACH LINES ❑-LEACHING CHAMBERS 1 v VYu{ ft 0 <br /> DISTANCE TO NEAREST WELL, ft FOpU�N AT}"�IIQ�jN rr1I ft R P�t T L ft — <br /> FILTER BED 4 WIDTH ft LENGTH �} �F eI 1�L� PITI{{EhhI ��d ft r� <br /> gd <br /> DISTANCE TO NEAREST WELL ft FOU4,Q IOI 1 f1I4�a-1tMR L s"wJ' ft c ^ 'e <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 /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft i <br /> EPS R ID TH <br /> DIST E AR LL ft UNDATION P P PE LINE ft <br /> I <br /> 1 REBY CERT THA HA P E HI PPL1C ION AND THLWOK WI^LINCE 1T AN J UIN OUNTY <br /> O INA S, AT AWS A RULES ANT <br /> 7 <br /> MINIMUM 24 HOU DVA`NCE�N`OTICE REQUIRED FOR INSPECTIONS–PLEASE CALL(209)953-7697 <br /> SIGNED ?� �l(a �✓ –+ TITLE DATE-77 <br /> / 8 <br /> +rr- <br /> P 1 <br /> i <br /> i <br /> S NUN O N <br /> ..S Vl N E T L <br /> – DEPARTMENT USE O LY <br /> Application Accepted By T Ddr AreaEmployee 11)# 1–jFinal Inspection By UP217 Date 13 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> f COMMENTS CC. <br /> I <br /> PE SC Received C Amount Date Permit/ Invoice# Permit 1D#,. <br /> s Code INFO B Cash Remitted Service Request# <br /> 0 5 a <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22!2003 <br />