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10/05/2004 15:25 4640138 ENVIRONMENTAL HEALTH PAGE 03 <br /> �iSITE WASTEWATER TREATMEN YSTEM PERMIT <br /> SAN JOAQIJW COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 3O VEBER AVE•3°f FL-STDCKTON CA 95202 - (209)468Zd20 <br /> NON-REFONDAB,E PERMIT CAL[,(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> -' JoB ADDRESS CITV/Zir 11• <br /> -&p-? 5� > <br /> APN PARCEL SI7J: v <br /> CROSS STREET � <br /> PHONE <br /> OWNER M1'nME <br /> I <br /> OWNER ADDRESS CITY/STATE/7.Ir <br /> PHONE <br /> CON'TRAC'TOR <br /> CONTRACTOR ADDRFSS CITV/STATE/71P <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER F.XrIRATIoN DATE. <br /> WATER TABLE DEPTH: 1L GrOGRAPHICAL INPORMATION: Cnordinates X V <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIWADDITION ❑ ENGINFER DESICNED/ALTERNA'r IVF, <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE a COMMERCIAL ❑ OTHER <br /> NUMBER OF Liv'INc.UNITC: <br /> NUMBF,R OF HEDROOM97 NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK 7YrE/MnG <br /> CAPACITY Eul 0 OT COMVAKTMF..NTS <br /> ❑ GREASE.TRAP T\'PP/MEG <br /> CAPACITY_ W11 #OF COMPAR'rMP.NTS <br /> ❑ <br /> PKC TX PLANT DISTANCE TO NEAREST: WELL <br /> R FOUNDATION I) PROPERTY LINE A <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLoSED SYSTEM) <br /> p LEACH LINES p LEACHING CHAMBERS <br /> #OF LINE$ LENGTH OE LINrs ft <br /> tt FOUNDATION ft PROrEKTY LINE ft <br /> DISTANCE TO NEAREST WELL ft <br /> WIDTH ft LENGTH ft DEPTH <br /> ❑ FILTER RED ft <br /> DISTANCE TO NEAREST WELL tt FOUNDATION _ft rRUPERTY LINE <br /> .. <br /> El MOUNDED WInTR _11 LENGTH <br /> ft DEPTH ft <br /> (t POUNDATION R PRt1PERl"V LINE R <br /> DISTANCE TO NEAREST WELL R <br /> WIDTH R LENGTH ft DEPTH_ <br /> ❑ SUMPS ft <br /> (t FOUNDATION ft PROPERTY LINE <br /> DI.STANCF.TO NEAREST WELL ft <br /> ft DEPTH_ <br /> L3 DISPOSAL PONDS WIDTH_ ft LENGTH R pROPERI"V LINE R <br /> DISTANCETO NEAREST WP.LL fl FOLINDA'rION <br /> R11 DFrTH� <br /> 0 SEEPAGE PITS WIDTH __IL LENGTH it <br /> DISTANCE TO NEAREST <br /> WELL R rOUNDATION ft PROPERTY LINE <br /> 1 Hr.REB)'CERTIFY'THAT 1 HAVE PREPARED T IS APPLICATI LAWS AND RON AND THE WORK WILL <br /> ULES ArvD EGU nT1ONS O FSAN JOAQUIONE IN ON COUNTYWITH SAN JOAQUIN COUNTY ORm MANCE$ <br /> MINIMUM 24 HOUR ADVANCE NOTICE PF.QUIRED FOR INSPEC"f IONS-PI.F.ASE CAIJ (2IM)953-7697 <br /> TITLE DATE <br /> SIGNED <br /> [ <br /> DEPARTMENT USE ONLY Froployce IDd <br /> Date Are.T <br /> Application Accepted BY Date [3 SPECIAL PERMIT-Approved by <br /> Final Inspection By pit/Sump Soil Character: <br /> Character of Soil to Depth of 3 Pt: <br /> COMMENTS <br /> Permit/ Invoice# Permit IDS <br /> Received Check#/ Amount Datc Service Re ­51PE SC Cash Remitted <br /> Code INPO BV a-- <br /> ONSITE W ASTEW ATFR P ER`A IT <br /> a.-0I-001 <br /> 10/05/2004 TUE 14:57 [T%/RX NO 76101 .004 <br />