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ONSITE WAS' NATER TREATMENT SYST- -4 PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE3ARTMENT 304 E WEBER A�w0—FL-STOCKTON CA 95202 - (209)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> LOW�NER <br /> S 2Gs7G �vdcril M14CK✓1«".4P CITY/ZIP ^�t/YIE�TS QS22, m <br /> ET 1LQ �nJ AA APN OZ/- /`O�/ ' PARCELSIZE �� v <br /> y�I ^. <br /> E VA1,PfF - AK ,f lellwJ� PHONERESS 4��07NOJZ�N /-/A�A(IGtI` iwAJ CITY/STATE/ZIP Cl-EMEA)MCAOPHONER IY <br /> CITY/STATE/ZIP <br /> CONTRACTOR ADDRESS <br /> LICENSE LI ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: -� /DD R GEOGRAPHICAL INFORMATION: Coordinates X <br /> Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION <br /> ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ DESTRUCTION <br /> LJREPLACEMENT <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE <br /> ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: <br /> NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MPG <br /> CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG <br /> CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL <br /> R FOUNDATION R PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE_ TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES El #OF LINES LEACHING CHAMBERS LENGTH OF LINES ftR <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ft LENGTH R DEPTH R <br /> L3 FILTER BED R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE <br /> R LENGTH ft DEPTH ft <br /> L3 MOUNDED wlDrx R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE <br /> R LENGTH R DEPTH ft <br /> ❑ SUMPS WIDTHR <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE <br /> R LENGTH R DEPTH ft <br /> LI DISPOSAL PONDS WIDTH R PROPERTY LINE ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION <br /> ft DEPTH ft <br /> El SEEPAGE PITS NUMBER-WIDTH <br /> DISTANCE TO NEAREST WELL <br /> R FOUNDATION it PROPERTY LINE R <br /> 1 HERE BY�CE�{FY THAT 1 DINANC PREPARED THIS <br /> LAWS ANDION AND THE WORK WILL BE RULESA AND REGULATIONS OF 3 WITH SAN JOAQUIN COUNTY <br /> N JOAQUIN COUNTYW <br /> N 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> TITLE d/t�NE� DATE <br /> SIGNED <br /> 4—_ <br /> u1 <br /> i <br /> A- TV <br /> 2 <br /> , \ \ DEPARTMENT E Y <br /> Application Accepted By <br /> V Date Area Employee ID# <br /> Final Inspection By <br /> Date i6�lJ� ❑ SPECIAL PERMIT-Approved by <br /> Pit/Sump Soil Character; <br /> Character of Soil to Depth of Ft: <br /> COMMENTS <br /> vl <br /> ReceivedCheck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Remitted <br /> PE SC Service Re Best# <br /> Code INFD B ash <br /> ONSITE WASTEWATER PERMIT' <br /> 42-02-001 <br /> 12/22/3003 <br />