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Ll Z0 ONSITE WASTE" ' TER TREATMENT SYSTEVaUFRMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP,\F 304 E WEBER AVE STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT A k -AL (LUVI YJJ-/OY / IA)K IJN.Ir EI.1 w;1411 r ArItta3 I I EAK UKUM "A In ,JJUnu <br />.JOB ADDRESS ✓ /Cp(/CITY//ZIP (1 <br />CROSS STREET /� } APN �r ! ` O� PARCEL SIZE <br />OWNER NAME PHONE <br />Zo l S `7-P 0116) <br />`/��' ,/Z <br />OWNER ADDRESS � � CITY/S E/ZIP 1� J <br />CONTRACTOR �� PHONEF`/�j1/�/L <br />CONTRACTOR ADDRESS CITY/STATE./ZIP <br />LICENSE ❑ C-42 ❑ C-36 O'IIIIiR NUMBER EXPIRATION DATE <br />TABLE DEPTH: <br />ft <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />FWATER <br />Ci,cJ PERC TEST (S) <br />NUMBER <br />LAND USE APPLICATION # <br />LENGTH OF LINES It <br />TYPE OF WORK: <br />❑ NEW INSTALLATION <br />Cl REPAIR/ADDIT N <br />EN INNEEE,%DppIGNE1b/ TER ATIVE <br />❑ REPLACEMENT <br />DESTRUCTION <br />Y`b,�//ll"sslliiuy i <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />C7 PKG TX PLANT <br />DIsTANCE'ro NEAREST: <br />WE1.1. It FOUNDATION <br />It PROPERTY LINE ft <br />U LIFT STATION <br />SIZE <br />TYPE OF PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br />Amount Date Permit/ <br />Invoice # <br /># of LINES <br />Code <br />LENGTH OF LINES It <br />By Cash <br />Remitted Service Request # <br />DISTANCE TO NEAREST <br />WELL <br />fl <br />FOUNDATION <br />It PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />R PROPERTY LINE tt <br />❑ <br />MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />R <br />FOUNDATION <br />ft PROPERTY LINE I't <br />❑ <br />SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ' ft <br />DISTANCE TO NEAREST <br />WELL <br />It <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />1 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.9) 95 <br />IONS— PLEAS/J <br />SIGNED 1 M 24 OUR �DVA�CE NOTICE REQUIRED TOREN�Jj�T—��" 1 /C!l�/FV tiht�CVDATE�9 <br />S <br />N, <br />DEPARTM("T USE ONLY <br />Application Accepted B 1v Date /�� %�t73 Arca Employee ID# <br />Final Inspection By _ Date l� / O� El SPECIAL PERMIT - Approved by <br />Character of Soil to;D ,th of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS /i�,�/L1�-E li.Gllwk,�A 42-$ me &" /PW� <br />PE <br />SC <br />Received <br />Amount Date Permit/ <br />Invoice # <br />Permit ID# <br />Code <br />INFO <br />By Cash <br />Remitted Service Request # <br />42-01-001 <br />12/2/02 ONSITE WASTEWATER PERMIT <br />