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ONSITE WASTkr.., ATER TREATME -PERMIT -5 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT C LL( 09)953-7669/7 FOR INSPECTIONS e f,,NPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS '� � �''✓' n K CITY/ZIP <br /> :j <br /> A / m <br /> CROSS STREET G� �� APN O� /�/'^' � PARCEL SIZE � (AG p <br /> 7 v <br /> OWNER NAME /y /9 .�/y /,� `� P LONE,-- 41/- `.22� - y <br /> OWNER ADDRESS 5-31 .3-3 /v 1 II / "� //Lt4-�ITY/STATE/ZIP <br /> CONTRACTOR 3,A �• PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# — LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE JXCOMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: .n NUMBER <br /> -01F�yBEDROOMS: f� NUMBER OF EMPLOYEES: ._�/f "\ <br /> SEPTIC TANK TYPE/MFG err d� �(�U Lr CAPACITY Q(/ gal #OF COMPARTMENTS pG. <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> A <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL /00 ft FOUNDATION ft PROPERTY LME <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED STEM) <br /> . LEACH LINES LEACHING CHAMBERS �2- #OF LINES_ ; LENGTH OF LINES TCS ft <br /> DISTANCE TO NEAREST WELL 00 ft FOUNDATION /LO 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 WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI ft <br /> SUMPS WIDTH ft LENGTH / ft DEPTH ft <br /> DISTANCE TO NEAREST WELL (0 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> v <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft Q <br /> 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 /> MIN)MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTI S-PLEASE CALL(209)953-7697 <br /> r �, 0 <br /> SIGNED G/ TITLE DATE <br /> –NOW V <br /> / t <br /> "40 LA <br /> ! i <br /> G- <br /> KAA <br /> OF <br /> E <br /> J A <br /> O M Fy <br /> DEPARTMENTUSEONLY ARTMENT <br /> Applications Accypted ^` <br /> WoDate ( -1��S Area Employee ID# (� <br /> Final Inspe"cn y ��x Date io?� yc3� ❑ SPECIAL RMIT roved by <br /> Character o oil to Depth o 3 Ft: Pit/Sump Soil Character: f <br /> COMMS TS / <br /> r 0 <br /> r✓I5 e <br /> PE SC Received Chec Amount Date Permit/ I ice yq;� Permit ID# <br /> Code INFO B� as Remitted Service Re uest# l V l <br /> Zl�v aS0 Cf 50X- ab <br /> 42-02-001 <br /> x1.2/22/2003 <br />