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ONSITE WASTETER TREATMENT,SYSTEICERM1T <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAI,TIt DEPARTMENT <br /> E WEBER AYE -3°S eL-STOCKTON CA 95202 - (209),468-3420 <br /> NON-REFUNDABLE PERIWIT CALL. 9 953-7697FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> Jolt ADDRESS17 CI'1'v/Llv <br /> M <br /> CHOSS'S"f'Rt:ET APNL <br /> PH Nt. R <br /> Er t"n r"'a" <br /> OWNER NAME -�.�'^=�- ( C �• <br /> OWN'ERADDRESS - CITYISTATtJZIP <br /> / C, <br /> /• l / /.::, �' ..��'( PHONE <br /> CONTRACTOR 9 <br /> C11ti1STAT E/Z I l' •I - { <br /> CONTRACTOR ADDRESS ,J <br /> v LICENSE <br /> C-42 ❑C-36 OTHER NUMR{t:R Cis c1 EXPIRATION DATE <br />' WATER TARH,E DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> f ❑ PERC TEST it BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: )4 . NE%%INSTALLATION Q REPAIR/ADDITION ❑ ENGINE"ER DESIGNED/ALTERNATIVE <br /> 4 REPLACENIFNT ❑ DESTRUCTION <br /> INSTALLATION WILLSERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER <br /> NUMIIt.R OF LIVING UNITS: NIIMI3ER OF 8 DROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/n7 FG li;:C t �S c[• CAPACITY fG'_C[ gal 4 OF COMPARTMFNTS <br /> ❑ CREASE TRAP TYI'F./MI'G CAPACITY gal 4 OF COMPARTMENTS <br />� ❑ PKC TX PLANT DISTANCE To NenRt:ST: WELL /75 ' <br /> ft FOUNDATION / Z f fl PROPERTY LINE <br /> h ❑ LI FT STATION_ SIZE TYPE OF PUMP 0 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I <br /> Ff LEACH LINES ❑ LEACHING CHAMBERS #OF LINES �� LENGTH OF LINES C C, tt <br /> - - - DISTANCE To NEAREST' WELL � S_'7 � ft FOUNDATION PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH tt LENGTH fl DFPTH ft <br /> DESTANCETO NEAREST WELL ft FOUNDATION tt PRoPE=RTv LINE ft <br /> ❑ MO(1N'UI?Il 'VN,IDT'H - f1 LI,NII'lll n DI{I'T}I 1't <br /> DIS'I'ANCE'I'o NEAREST WELL 11 FOUNDAI'ION _ 11 PROPI.iR'TY LINE f <br /> ❑ SUMPS WmTH 11 LEiNciTil fl DEP'Ifl ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION f1 PROPERTY LINE ft <br /> Ll <br /> ❑ DISPOSAL PONDS Wun'H 11 LE:NGT'II tt DI_P"I'EI ft <br /> DISt'ANCE.-ro NEAREST WPLL 1L FOl1NDATEON � It PROPERTY t.INF fl <br /> SEEPAGE PITS Num1wIi_ Wurrll 'J I't D1:1,111 It <br /> DISTANCE'1'O NEAREST Wlll.l. /5 L�r_ I'l Tol IN DAT ION fl I'ROPHRTY LINE <br /> 1 HFRt;It]'Ct:R'1'I1 Y THAT[HAVE,PREPAREDTHIS APPLICATION ANI)THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ` <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN.IOAQUIN COUNTY. <br /> MINIMUM 24 Nl UR ADV%NCE:NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL,f2()y1 953-7697 <br /> SIGNED TITLE ..; .rr.I. DATE <br /> 14, <br /> r l <br /> IL—L22 ? I <br /> F <br /> x <br /> -1 0 <br /> —6 All <br /> o rev c <br /> Nr <br /> J 10 <br /> DEPARTMEIV 'E L, <br /> Application Accepted By Date _ [J�-(+� Arca Employee ID# <br /> l I'lllal InSpel't11111 Its �"` Dale <br /> IJ SPECIAL -Approved by <br /> Character of Soil to Deplh of 3 I'll: Pi1lSwnp Soil Character: <br /> COMMENTS d 'rO �� <br /> PE Sc Received r, c Amount ate Permit! <br /> Code INFO B' Cas Remitted Service Request 9 Q <br /> _ IF, <br /> 42-02-001 <br />