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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> wNON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ��q+ <br /> JOB ADDRESS - - CRY21P <br /> CROSS STREET APN PARCEL Boa b <br /> OWNER NAME PHONE <br /> OWNERADDRESS CITY/STATE21P <br /> CONTRACTOR -l. PHONE <br /> CONTRACTOR ADDRESS CITY/STATFRIP <br /> LICENSE ❑C-42 ❑CJS OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERCTEST # BUILDING PERMIT# LAND USE APPLICATION# �FaG�tiCa— <br /> TYPE OFWORK: ❑ NEw INSTALLATION ❑ REPAIWADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCUU. ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPEIMFG CAPACITY 921 #OF COMPARTMENTS <br /> ❑ GREASETRAP TY E/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCETONEAREST: WELL It FOUNDATION ft PROPERTY LINE R <br /> w❑ LIFT STATION Sum TYPE OF PUMP O PKGTXPLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF❑NES LENGTH OF LINES It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION B PROPERTYLINE R <br /> ❑ FILTER BED WIDTH It LENGTH R DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY❑NE It <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY❑NE ft <br /> ❑ SUMPS WIDTH It LENGTH ft DEPTH It <br /> DISTANCE TO N EANEST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGEPITS NUMBER WIDTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft. PROPERTY LINE fl <br /> I 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> Ell <br /> O O N <br /> E <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �--'(I�.� �— Data Area Employee ID#�, L; <br /> Final Inspection By Data ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PIVSump Soil Character: <br /> COMMENTS <br /> PE SCRecelved Check!N Amount Date Pemnit/ Invoice# Partnit l0# <br /> Code <br /> INFO 13 �-Ceeli Reified (' SemiceRequest <br /> # <br /> rJ J21 LC- �L.L�i <br /> 424)1 ONSRE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 1N4/o7 <br />