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NSITE WASTEWATER TREATMENT "STEM PERMIT <br /> SAN JOAQUIN COUNTY``_�RONMENTAL HEALTH DEPARTMENT 3041—/BER AVE-3µO FL-STOCKTON CA 95202 -(209)468-3420 <br /> .� NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> 1 2r <br /> JOB ADDRESS X VCITY/ZIP IV�L LG 1 <br /> H <br /> CROSS STREET r APN 05 i- / Z312 <br /> 1 12 J/ PARCEL SIZE C - <br /> nn 1A <br /> OWNER NAME 4y!t"•}t )L Y, u 5 Y -2— I <br /> PHONE <br /> ?, ' �f <br /> OWNER ADDRESS ,/ {? (� ' CITY/STATE/ZIP `",f�'`t r f� L{S Z Z •. <br /> CONTRACTOR -f PHONE <br /> /1 / , <br /> CONTRACTOR ADDRESS t,� F 1y,"'I/V i�l�f hilir,t.) CITY/STATE/ZIP 1 G��411 <br /> I LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATERTABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> r FERC TEST(S) NUMBER LAND USE APPLICATION# i <br /> C <br /> TYPE OF WORK: ❑ NEW INSTALLATION Cl REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER 1 <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES fl <br /> DISTANCE TO NEAREST WELL - ft FOUNDATION tl PROPERTY LINE fl <br /> - ❑ FILTER BED WIDTH ft LENGTH fl DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYI.INE ft <br /> ❑ DISPOSAL PONDS WIDTH fl LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH Il DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION tl PROPERTY LINE Il <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPfiCTTIO S-(PLEASE CALL(209)9$3-7697 /7 ) <br /> SIGNED �L�^'�`� `.. TITLE (/�r'GI 1 DATE <br /> I IV <br /> lee C. j 46Ca. <br /> '1\/EIJT <br /> UU <br /> HH <br /> *EIIIIME t <br /> DEPARTMEN�Ty ELY q <br /> Application Accepted By�- Date 1 �� rea r Employee ID# O <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PiUSump Soil Character: <br /> COMMENTS <br /> s <br /> PE Sc Received Amount Permit/ <br /> Code INFO v; Cash D Remitted to Sery a # Invoice# Permit ID-west <br /> 42-01.001 <br /> 11/2/02 ONSITE WASTEWATER F-.RMIT <br />