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ONSITE WAST VATER TREATMENT SYSTY PERMIT <br /> 5..;A( QUIN COUNTY ENVIRONMENTAL HEALTH DEAARFMENT 304E WEBER AVh—J FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL <br /> CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> p <br /> JOB ADDRESS 137U CITY/ZIP Cr, y <br /> L Y m <br /> CROSS STREET ®IA-O�i/`J-iYp-�i pPN 141-20040 PARCEL SIZE ��'*J�/JA�, zo <br /> OWNERNAME PHONE 7 � <br /> OWNER ADDRESS � ' CITY/STATE/ZIP lylnjsc ., <br /> a / <br /> CONTRACTOR K� � CSI I, d—ex- PHONE R <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y W <br /> PERC TEST(S) NUMBER LAND USE APPLICATION# —5%-1 <br /> % <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE V; <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFO CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS If OF LINES LENGTH OF LINES R v <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ FILTER BED WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> Cl SUMPS WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH R -LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ SEEPAGE PITS WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> 1 HEREBY CERTIFY THAT I 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. <br /> MI IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 �1 <br /> SIGNED TITLE DATE100 <br /> 11L OL4 <br /> r <br /> lz <br /> U <br /> E VI N E T <br /> �r <br /> D PARTMENT US k NLY ' <br /> Application Accepted B - / Date 1 ZN�F`�d3� Areal �' Employee ID# 4 S �" <br /> Final Inspection B - ate e�i, ❑ SPECIAL PERMIT-Approved by <br /> S <br /> Character of Soil to Dep of 3 Ft: Pit/Sump oil Character: <br /> COMMENTS 71�%iCG7 �L/ .7�YsiG�sZ'v J! tiiH`1/36/?C63CG/�(�]i <br /> PE SC Received Amount to Permit/ Invoice# Permit ID# <br /> Code INFO v ash Remitted Service Request Is <br /> 42-01-001 ONSITE WASTEWATER PERMIT <br /> 12/2/02 <br />