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ONSITE WAST( ''VATER TREATMENT SYSTFO**% PERMIT <br /> "SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAIITMENTj <br /> 304 EWEBER AVE -3rr'FL-STOCKTON CA 95202 - (209)468-3420 i <br /> 'NON—REFUNDABLE PERMIT CAL.L1209a.953-7697 FOR INSPECTIONS <br /> - EXPIRES 1 YEAR FROM DATE ISSUED ; <br /> ,JOB ADDRESS 34 � y <br /> -- CITY/ZIP <br /> CROSS STREET tAn n I } y/ M <br /> n APN f O PARCEL SIZE F J ! <br /> OWNER NAME tJ a !r'W rr s PHONE <br /> OWNER ADDRESS <br /> CITY/STATE/ZIP 1V 1 l <br /> CONTRACTOR <br /> } W PHONE r <br /> CONTRACTOR ADDRESS CITYISTATElZI P <br /> LICENSE:i ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE bQ <br /> WATER TABLE DEPTH: B GEOGRAPHICAL INFORMATION: .,Coordinates X Y: + ' <br /> i <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF.WORK: ❑ NEW INSTALLATION . ❑ REPAIR/ADDI ON 0 ENGINEER DESIGNED/ALTERNATIVE Pj.;i <br /> ❑ REPLACEMENT � DESFRUCTJON. J <br /> INSTALLATION.WILL SERVE: ¢ ;%:❑;RESIDENCE •© ,COMMERCIAL ❑ ,OTHER y <br /> :. <br /> NUMBER OF LIVING UNITS: - •NUMBER OF BEDROOMS: NUMBEROFEMPLOYEES:' { '• F I <br /> SEPT[CiTANK CAPACITY <br /> TYPFJMFG tt ;,. j,.:r:' r: ,'? • 7 <br /> gal #OF COMPARTMENTS <br /> ❑ 'GREASETRAP ``�TYPE/MFG" t l h. CAPACITY gal #OF COMPARTMENTS Tom' <br /> ❑ PKG TX PLANT' DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY[INE fl <br /> ❑ LIFT STATION +, SIZE' TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I <br /> ❑ LEACH- LINES D LEACHING CHAMBERS #OF LINES LENGTH.OF LINES fts <br /> % DISTANCE TO NEAREST- WELL ft I,1 FOUNDATION ft PROPERTY LINE ft, <br /> ❑ FILTER BED WIDTIO R : LENGTH + #" ft DEPTH ft' <br /> DISTANCE TO NEAREST WELL ft ,FOUNDATION ft PROPERTY LINE ft, <br /> ❑ MOUNDED WIDTH fl LENGTH R DEPTH ft r <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft k <br /> ❑ SUMPS- WIDTH ft LENGTH A- DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 1 <br /> I f <br /> (3 DISPOSAL PONDS WIDTH ft . LENGTH A DEPTH ft <br /> DISTANCE TO NEAREST WELL71. <br /> ¢ ft FOUNDATION A PROPERTY LINE ft <br /> ❑ SEEPAGE PITS ' " 'WIDTH" r.11` W°, LENGTH . 'd: i , .' ft:' r 'it i fts?Ili `'DEPTH''!' <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> I HEREBY CE I Y THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,¢ i <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, r—f yl <br /> MINIMU7 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 + <br /> SIGNE Lam• TITLE DATE <br /> ji <br /> 1 177 <br /> APNT <br /> E E , <br /> ' r ; <br /> i I . <br /> 1 <br /> E e <br /> i <br /> SA,143 A <br /> NT l K ALT 01 S! i, C7 if <br /> F <br /> ' bt' • h j <br /> '•�-,.•: � .r� ;. i'�" rte'"�`A x=�'tet� , -- =r= ice' -:� ;.� �-���-,..a --�� �- .S <br /> 1 i ! <br /> 1.4:1Id.l �:t7 .; 7i}, tI`: fS !ro 75 :+lt •u5.,� 1.'�i, -r- .t e�. ;r {( rt i. �� f!i 11 - I ' <br /> :.2i"ITs rpr k �, I` <br />.. I <br /> DEPARTMENT USE ONLY <br /> Application Accepted B 3 (i 1n O ( r <br /> pp P Y Date Area 1 v Employee ID# 1 <br /> FinalrinspectlonBytl" 'U ,k `�` U a� ' Date 11 SPECIALIPERMiT Approved by <br /> .FIUI?`> ! .-A... - ., P,f- ••'� SfE(i�'�{;A i.:`:si {lE'•.A'` <br /> Character of Soil to Depth of 3 t: Pit/Sump'Soi1 Character <br /> COMMENTS <br /> ^D �nJ� <br /> o33,: .rllL,fli'S 1�1t:P',N;, .y41;s: . '.f3! r h ,i; T <br /> d il.!, , -!t'.r?. f.'s':+L,!. li l'1 `- - , -F ,:.eli C' .., .17: <br /> PE SC Receivedhec Amount "Permitl�"'" <br /> Code INFO B ash Remitted UBte Service Request# Invoice# Permit IN, <br /> 42.01-001 <br /> 12!2!02 _ ONSITE WASTEWATER PERMIT <br /> . z <br />