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ONSITE WA. ZWATER TREATMENT SYS �/M PERMIT OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER rAl'E -3NO FL-S'1'OCKTON CA 9$202 - (209)468-3420 N-REFUNDABLE PERMIT CALL.(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED n B ADDRESS CITY/ZIT' -i :ROSS STREET A P N /� PAR('FL SIn OWNER NAME: >✓G.tQ _ I� ft 1111-7 tv v ' y� ��d �_,�Q n J IIIONEJ�`-1 � �ti/�<��/ Yi OWNER ADDRESS STIf�cl CI��{��1W1 fr _t/t • rry/STAT �(5�00✓1 �1 CONTRACTOR �1`P.V l (2. �YUY `I� �� V \ty- PHONE:��z G)fa7 J�v I CONTRACTOR ADDRESS A CITY/STATE/ZIP LICENSE LI C42 (3C C-36 �OTHER NUMBER 057 EXPIRA'T'ION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERCTEST(S)y NUMBER I LAND USE APPLICATION# O'f) L FY E OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/A N E ❑ REPLACEMENT ❑ DESTRUCTION Q INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ O'rHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: C-' ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP 'TTYPE/MFG>W 31+' CAPACITY gal #OF COMPARTMENTS _ e 1 Tor:2!(iph w'a.) ❑ PKG TX PLANT DISTA CC ToNBAtiESI: WELL fl FOUNDATION fl PROPERTY LINE ft ❑ LIFT STATION SIZE, +i n f. TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL fl FOUNDATION fl PROPERTY LINE It ❑ FILTER BED WIDTH ' .'; fl LENGTII tt DErr1I ft DISTANCE TO NEAREST WELL fl FOUNDATION It 11ROPERTY LINK fl ❑ MOUNDED WIDTH R LENGTH Il DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH it DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH A DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ti ❑ SEEPAGE PITS '-WIDTH 1 t1OfI8z, ft LENGTH ft DEPTH fl DISTANCE TO NEAREST WELL ftFOUNDATION it PROPERTY LINE ft I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE:WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE:CALL(204)451-707 SIGNEDTITLE DATE 7Z/ :Z� / F . PIL---- IAN UL'; tW ON IM A! r=- DEPARTMENT USE ONLY ^� Application Accepted By Date / - O Area L I ' Employee ID# J C Final InspectlDh By. 'i` t Date ❑ SPECIAL PERMIT-Approved by Character of Soil to De th of 3 Ft: Pit/Sump Soil Character: COMMENTS D PE SC Received eck#/ Amount Date Permit/ Invoice# Permit ID# Code INFO By Remitted Service Request# 42-01-001 _ 12/2/02 ONSITEWAS"f1iWATP.R PERMIT