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't <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JO&QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AvE-3y°FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)955-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS _ - � CITY/ZIP �J <br /> PARCELSIZE JL!' + d <br /> API\ <br /> CROSSSTREET � •,! L l�Li � <br /> A PHONE ^•(.'- ![ 4.: r� <br /> O%"''ER NAME •:`''1 "�.��1:_ <br /> CITYlSTATEIZIP <br /> OWNER A DDRESS <br /> }kms �=1 i .[,` j�_•-�'�I I _ PHONE <br /> i~I <br /> 1 CONTRACTOR - _ <br /> CITYISTATE2IP <br /> CONTRACTOR ADDRESS r' 'I <br /> NUMBER EXPIRATION DATE <br /> LICENSE 13C-42 ❑C-36 OTHER I <br /> WA PER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: COOTd1na1¢5 X Y <br /> ( PERC TEST # r"', BUILDING PERMIT# LAND USE APPLICATION#0.I -'vLC� I <br /> ❑ REPAIR/ADPITION ❑ ENGINEER DESIGNED!ALTERNATIVE <br /> TYPE OF WORK: ❑ New INSTALLATION <br /> r <br /> ❑ REPLACEMENT 0 DESTRUCTION <br /> f INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF L1 V ING UNITS: N UM BER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> t <br /> ❑ SEPTIC TANK TYPUPAFG CAPACITY gai #OFCOMPARTMENTS •`�• <br /> r ❑ GREASE TRAP TYPEIMF0 CAPACITY gal #OF COMPARTMENTS <br /> ❑ <br /> R PROPERTY LSNE <br /> PKG TX PLANT DISTANCETO WELL R FOUNDATION <br /> R <br /> O LIFT STATION SIZE TYPE OF PUMP LI SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES 0 LEACHING CHAMBERS #OF LINES LENGTH OF LINES R <br /> DISTANCE TO NEAREST WELD R FOUNDATION It PROPERTY LINE <br /> R <br /> • _Ft LENGTH LENGTH ft DEPTH R <br /> ❑ FILTER BED WIDTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ft DEPTH ft <br /> LIMOUNDED WIDTH R LENGTH <br /> !+! ft PROPERTY LINE R <br /> DISTANCE.TO NEAREST WELL ft FOUNDATION <br /> {1 ` WIDTH R LENGTH R DEPTH R <br /> k ❑ SUMPS <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH ft <br /> h. DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> J r <br /> fl DEPTH ft <br /> ii <br /> LJ PITS NIOMBER WIDTH <br /> t DISTANCE TO NEAREST WELL. R FOUNDATION R PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE.WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 1 <br /> ` NfIN�IfhtUM/24H�UU`H ADyANCE NOTICE RF.OUIREn FOR iNSPBCTIO\S/-(,PLEASE CALL(209)953-7697 <br /> SIGNED h <br /> i .� �d- 'f/'.0 TITLE rY / DATE . .+,L <br /> Y•'�" �1 <br /> If <br /> i' <br /> h <br /> t <br /> i <br /> + i <br /> R N EN A <br /> - DEPARTMENT USE Y <br /> .I •, �. Area Employee lD# <br /> Application Accepted By <br /> G Fin Date ❑ SPECIAL PERMIT-Approved 6y <br /> Final Inspertion By <br /> Character of Sol[to Depth of 3 FI: PiUSamp 5031 Character: <br /> 'COMMENTS <br /> 1 1 PE SC Received Amount Date Permit! Invoice# Permit ID# <br /> iii Code INFO B Cash -Remitted Service Re a" # <br /> Z7- X121: r 33 g �� *iq 00 1 <br /> ` t 1 ' • -+-LLQ M1M1 - ONSITEW ASTEWATERTPERMIT <br /> 42-02-DDI <br /> rt IV22rz003 <br />