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-9pr 7x MR w ffl..� 'p-/�J <br /> ONSITE WA�')EWATER TREATMENT SY, M PERMIT41-p4te®� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT:..✓EPARTMENT 304 E WEBEti-'VE -3"FL-STOCKTON CA 95202 - (209)468-34 0 <br /> NON-REFUNDABLE PERMIT /�- CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS �✓' i T �.s� CITYIZIPLA <br /> j7A �J � <br /> CROSS STREET ( A P N / ~ / PARCEL SIZE G <br /> OWNER NAME PHONE <br /> IV <br /> -¢�- 3�e/ <br /> °"' � � � <br /> OWNER ADDRESS � ��r }� CITYISTATE/ZIP <br /> CONTRACTOR ✓ .V ��G PHONE �✓�3 <br /> CONTRACTOR ADDRESS 7 z,- CITYISTATEIZIP -Q d" RS <br /> LICENSE OC-42 ❑C-36 OTHER NUMBERdc' EXPIRATION DATE [kms+ <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1 <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: 4K NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED IALTERNATIVE • �1 <br /> ❑ REPLACEMENT L3 DESTRUCTIONov d. 7k <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: �j NUMBER OF EMPLOYEES: <br /> E I SEPTIC TANK TYPE/MFG 7�ST -/ &'A-/—CAPACITY !/ gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL l fV ft FOUNDATION ^r ft PROPERTY LINE �- O ft <br /> ❑ LIFT STATION SIZE TYPE PUMP ❑ SAND 0[L SEPARATOR(ENCLOSED SYSTEM) <br /> &2� <br /> LEACH LINES LEACHING CHAMBERS L #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL <br /> FOUNDATION� ft PROPERTY LINE <br /> I <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft ' PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTHft D�¢' TH ft <br /> SiJi17PS)a DISTANCE TO NEAREST WELL ft j•OU ATIOj R PROPERTY LINE ft <br /> WIDTH a ft LENGTH / DEPTH 140 ft <br /> �� • <br /> DISTANCE TO NEAREST WELL FOUATION L�2� ft PROPERTY LINE 45, ft <br />' ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION -ft PROPERTY LINE ft <br /> ❑ SEEPA ITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL. ft FOUNDATION ft PROPERTY LINE ft <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 /> r <br /> MI MUM 24 HOUR VANCF TI R>:QUIRED FOR INSPEC NS—PLEASE CALL(209)953-7697 <br /> SIGNED ` � TITLE DATE Lt� 'O <br /> h , <br /> a <br /> Pe"I L-jA"4iAA <br /> nr <br /> LT -K <br /> Cy' EPARTMENT U E O L� <br /> � `r <br /> Application Accept By Date Area Employee ID# <br /> Final Inspection B Date �� f ❑' SPECIAL PE MIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: !i <br /> CO MENTS Y <br /> 57 <br /> J <br /> PE SC Received Check#/ Amount Date Permit/ nvoic PermitID# <br /> Code INFO By Cash Remitted Service Request# <br /> lS M ° l OS 114 <br /> 42-02-001 J ONSITE WASTEWATER PERMIT <br /> 12122/2003 <br /> l 1 <br />