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` *avlINSITE WASTEWATER TREATMENPV-OVSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3""FL-STOC.KTON CA 95202 -(209)468-3420 <br /> NON-REFUNDA LE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE_ISS <br /> JOB ADDRESS y� J 'j CITY/ IF FI �r 6 1 <br /> CROSS STREET Ji i > <br /> _ APN SOS" ((DC� r f��H C"j <br /> / PARCEL SIZE c <br /> OWNERNAME 1 t�." tt,J �'1.J -77 5 -&i 1�1 '?/I <br /> C PHONE <br /> OWNERADDRESS C_ 1�.1? K c' I 0 <br /> 1 <br /> r CITY/STATE/ZIP /*5 !WJW( t''? <br /> CONTRACTOR ' JDA PHONE ']�Q 7 J <br /> CONTRACTOR ADDRESS ZZ 10' //l)y�+(/t C%ti'' �i CITYISTATE/ZIP �•'�'"^"I w r /5 —f 2 v <br /> LICENSE ❑C-42 ❑C-36 OTHER `+' ✓ NUMBER , ( //-���7 `AI <br /> � v •'�"� EXPIRATION DATE ! 30 <br /> WATER TABLE DEPTH: R GEOCRAPHICALINFORMATION: Coordinates X y l� <br /> PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Cl ENCINEERDESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION T <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG <br /> CAPACITY gal #OF COMPARTMENTS '\ <br /> r• <br /> '� ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> r• <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS OF LINES LENGTH OF LINES fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL 11 FOUNDATION it PROPERTY LINE ft <br /> i <br /> ❑ MOUNDED WIDTH fl LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH it DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> "w ❑ DISPOSAL PONDS WIDTH ft LENGTH it DEPTH ft <br /> DISTANCETO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH A DEPTH ft <br /> DISTANCE TON EST WELL fl FOUNDATION t1 PROPERTY LME fl <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARE THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> ATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 1 IUM 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEA,S.E CALL(209)953-7697 <br /> SIGNED TITLE�'r-`!+ ���'�•�� DATE �� <br /> FRO)N7AGE Reap <br /> /iOvQL/ / DN-RAIR IT-RAW <br /> HIGHWAY 99 <br /> DEPARTMENT USE ONLY }- r <br /> Application Accepted By (�` " Date , Area �- ,— employee ID#J 3 tl <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PHISump Soil Character: <br /> COMMENTS <br /> PE SC Received heck# AmountPermit/ <br /> Code INFO By as Remitted Date Invoice q Permit IDq <br /> I Servi uest# <br /> +111 ItIlp 59(41 147 <br /> 42-01-001 <br /> 1212/02 ONSITE WASTEWATER PERMIT <br />