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11 1 <br /> A! ONSIT IASTEWATER TREATMENT SYSTI+ MI <br /> ERT <br /> SAN JOAQUIN COUNTY ENVIRONMENT�EALTH DEPARTMENT 304 E WEBER AVE- FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT { �CALL 209 953-7697 FOR INSPECTIONS i EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �a5� I ` C• I L <br /> CITY/ZIP (J .t IF)2y <br /> _ CROSS STREET /�r ''(' APN I 1 7()"�J PARCEL SIZE <br /> OWNER NAME i f, - A-) �� <br /> � -Y�Yj�ll 1' (I L-c h wC _ 'IC. II PHO7,NE /� <br /> OWNER ADDRESS r;2 -- C ` I 'SU CITY/STATE/ZIP l,C,& CA 1 l A <br /> _ CONTRACTOR -'V t tJ. /,I '_ t v*)I K' `i :iG�C\?i--P-P 4 PHONE ? <br /> CONTRACTOR ADDRESS `IC L_ 1.y3(14+ ',111 � L,V.:'1��\ CITY/STATE/ZIP ! Grl <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X - y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION <br /> TYPE OF WORK: ❑ - NEW INSTALLATION ! ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> .� INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> �\ <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST::.WELL ft FOUNDATION R PROPERTY LINE $ �• i <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 1 <br /> .� ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft i <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH _ ft. LENGTH It DEPTH ft I <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE II ! <br /> ❑ MOUNDED WIDTH fl LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION _ R PROPERTY LME ft �1 <br /> ❑ SUMPS - WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION - ft PROPERTY LME ft <br /> ❑- DISPOSAL PONDS WIDTH - ft LENGTH -- fl DEPTH ft 11 <br /> DISTANCETO NEAREST WELL ft FOUNDATION - ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER - WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LME $ <br /> I <br /> 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 /> MTM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEApS CALL(209)953-7697 _ <br /> SIGNED (i/ A i(� \ Com„_. TITLE�' (; ��, S ' <br /> < 1'1 I,'. Ilf.'6 }'/� DATE <br /> i <br /> � t <br /> T <br /> f <br /> O <br /> i I DEPARTMENT USE NLV _ I <br /> Application Accepted BYZ ti (� t <br /> Date _ Area Employee ID# (L' <br /> Final Inspection By _ - Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft. Pit/Sump Soil Character <br /> COMMENTS <br /> I <br /> PE SC Received Checl / Amount Permit/ <br /> Code INFO By_ 'I-ash Remitted -- Pate • Service Re uest�#7 Invoice# Permit ID# <br /> W75 7573 <br /> 42-02 <br /> 12/22/2003 ONSITE WASTEWATER PERMIT <br />