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. ... ....--..r'-s..>.q.�w+v .,..w. ...�... _ .E,.. ,..r'... -o.:71Ft+..ra„rr6: .r�=.'�,.Rvd a-'+C�#�^A�.•i�a�A.. I I .. ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3-FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS � ' CI ('4- I I --"i 1 F' -j—'. CITY/ZIP rS” — ( -, CROSS STREET r iv F APN I ) I 1 - Z' PARCEL SIZE OWNERNAME � - i r -"C A'} !Il-. ,r �)ti L PHONE OWNER ADDRESS CITY/STATE-/ZIP CONTRACTOR I' PHONE. CONTRACTOR ADDRESS CITY/S'bkTFJZIP _� l LICENSE ❑C-42 ❑C-36 OT14ER NUMBER EXPIRATION DATE �`- WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y CS'I PERC TEST # BUILDING PERMIT# LAND USE APPLICATION#7 -e 27777 TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE ❑ REPLACEMENT ❑ DESTRUCTION I 1 INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: (, ❑ SEPTIC TANK TYPF/MFG CAPACITY gal #OF COMPARTMENTS II+ ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS ^ i ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LME ft r ❑ LIFT STATION SIZE_ TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) v^ I ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft rj I{I DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft i ❑ FILTER BED WIDTH ft LENGTH it DEPTH R DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl ❑ MOUNDED WIDTH ft LENGTH 4p ft DEPTH - fl DISTANCE TO NEAREST WELL ft FOUND.(TION ft PROPERTY LME..,--- R t. ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNLATION ft PROPERTY LINE ft n ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH -- R DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft ! DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME R Z I HEREBY CERTIFY THAT I 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(209)953-7697 r SIGNED TITLE _ L�-,-,.,'�- DATE i i I ! I � r I A I I 1I U C i!J i 'AC JIL 1 -7, \1RONI,E1,T {•fl" H i ` I i I d EPARTMENT USE O r/ Application Accepted By (�!'\_ C ti�Jj L{ Date / D� Area Employee ID#J C Final Inspection By Date ❑ SPECIAL PERMIT-Approved by .9I Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS t i PE SC Received Check#/ Amount Permit/ CoINFO B ash Remitted Date Service Request# Invoice# PermI11D# de ILL! „�. Z '� 217t."76' �7 V i 42.02.001 ONSITE WASTEWATER PERMIT I2r22/2003 J