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ONSITE WAI-7EWATER TREATMENT SYSPWM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI, APARTMENT <br /> 304 E WEBEh e -3"°FL-STOCKTON CA 95201 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 9$3-7697 FOR INSPECT[ONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> E; I} CITY/ZIP rn <br /> CROSS STREET <br /> t q APN <br /> l <br /> OWNER NAME PARCEL SIZE o <br /> E PHONE � <br /> OWNER ADDRESS <br /> CITY/STATE/ZIP <br /> CONTRACTOR <br /> �II 1 PHONE <br /> CONTRACTOR ADDRESS <br /> IIII CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER <br /> fEXPIRATION DATE <br /> Ei WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> PERC TEST #_ Y <br /> BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ -NEW INSTALLATION ❑ REPAIRIADDlTION <br /> ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> E: <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> !M�TALLATION WVE: ❑ RESIDENCE <br /> ❑ COMMERCIALOTHER <br /> BER OF L�VING ITS: NUMBER OF BEDROOMS: <br /> NUMBER OF EMPLOYEES: <br /> 0. SEPTIC TANK TYPE/MFG CAPACITY <br /> gal #OF COMPARTMENTS <br /> ?� ❑'� GREASE TRAP TYPE/MFG CAPACITY <br /> i gal #OF COMPARTMENTS <br /> I ❑{' PKG TX PLANT DISTANCE TO NEAREST: WELL <br /> ft FOUNDATION ft PROPERTY LINE rrn <br /> E ft Vj <br /> E ❑ Ei LIFT STATION SIZE TYPE OF PUMP ❑ SAND,OIL SEPARATOR(ENCLOSED SYSTEM) <br /> :1 ❑ LEACH LINES ❑ LEACHING CHAMBERS <br /> { #OF LINES LENGTH OF LINES ft <br /> II E! DISTANCE TO NEAREST WELL ft FOUNDATION $ PROPERTY LINE <br /> it ❑ FILTER BED WIDTHft <br /> ft LENGTH ft DEPTH ft <br /> I! DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ !MOUNDED WIDTH ft <br /> ii ft LENGTH ft DEPTH ft <br /> 1 DISTANCE TO NEAREST WELL ft FOUNDATION <br /> ft PROPERTY LME ft <br /> it ❑ +SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> 13I <br /> i! I <br /> it rl DISTANCE TO NEAREST WELL ft FOUNDATION <br /> 1!DISPOSAL PONDS WIDTH <br /> ft LENGTH ft ft PROPERTY LINE ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE <br /> a ❑ SEEPAGE PITS NUMBER ft <br /> WIDTH ft DEPTH ft <br /> it DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I Ei I HEREBY CERTIFY THAT I 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 /> MI <br /> OUNTY.MI 2 IL6UR VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE AL (209)953-7697 f. <br /> SIGNED / TITLE <br /> DATE <br /> EE <br /> i� <br /> S i <br /> O, r <br /> ,i <br /> �. . <br /> ,s <br /> I <br /> II <br /> Im <br /> E <br /> 9 t•i <br /> r <br /> ,: I <br /> l - =� —— •: =—�—�-u AEP_A-RT^J -T <br /> IEN _ SE.ONLY_ —:.Y._r�— <br /> Application Accepted By Date ' Area Employee ID# <br /> IFinal Inspection By Date 0 SPECIAL PERMIT-Approved by r <br /> Character of Soil to De of 3 Pit/Sump Soil Character: <br /> . <br /> COMMENTS S� I .��,• YS <br /> I i <br /> PE€; SC Received I Check#! Amount <br /> Code INFO B as Remitted Date Permit! <br /> ! n Service Request# Invoice# Permit[D# <br /> 4L 2z 2-1 �� b 7 2 00 <br /> 42-02-061 <br /> 12122/2003 ONSITE WASTEWATER PERMIT <br />