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ONSITE WAST. . . . _TER TREATMENT SYSTEM, __aRMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE ANO FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 JOB ADDRESS 119-0 3 T R CITYI'GtP <br /> T, A:: <br /> Z� v' <br /> r �^ <br /> CROSS SIRE �/�S APN 0'5-'J ~I 'D -A� PARCEL SIZE Y <br /> o <br /> dz <br /> OWNER NAME -e— �� S '�V C C./1/\ PHONE <br /> 1 y <br /> 1 OWNERADDRESS t I ma+ 1 CITY/STATE/ZIP <br /> CONTRACTORP I ION E <br /> CONTRACTOR ADDRESS CITYISTATEIZIPA q <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> I WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> I � <br /> i <br /> ElPERC TEST # rL— BUILDING PERMIT# LAND USE APPLICATION <br /> 4 TYPE OF WORK. ❑ NEW INSTALLATION ❑ REPAIR1ADDIT1ON ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> +I ❑ REPLACEMENT ❑ DESTRUCTION <br /> I INSTALLATION WILL SERVE: ❑ RESIDENCE © COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: •NUMBER OF EMPLOYEES: <br /> i ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> 1 ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> © FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED W113TH ft LENGTH ft DEPTH ft r <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 5 <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> D DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH fI <br /> I DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />! I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR AD CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> i SIGNED TI qo/� .SH��� DATE Z C! <br /> c :I <br /> i <br /> i <br /> F <br /> ® �• © ® •*® <br /> !J� d16 AC. A rr `NET-A <br /> )DALE ROAD <br /> PLAT <br /> moi �' ,. ;; •� -; <br /> Ji GED �� ����r� � ��_ �• <br /> 7 . 4' <br /> S N O <br /> w }� <br /> R t' 3 r1q 4 I"' is TMENT <br /> - — - -30 <br /> ' DEPARTMENT UL� ON <br /> Il Application Accepted By Dale2, 1 Area �/`�— Employee lD# <br /> l <br /> Final Inspection By . I.;.- Date ��3—n 5 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soll tp•Depth of 3 F. /rte PiUSump Soil Character: <br /> COMMENTS <br /> PE SC Received Check# Amount Date Permit/ invoice# Permit ID#S <br /> Code INFO B Cash Remitted Service Request# <br /> ZZ / <br /> ST-o ST-op q-7. .c <br /> 42-02-001 ONSITE:WASTEWATER PERMIT <br /> 12/22/2003 <br />� .T <br />