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ONSITE WASTEWATER TREATMENT SYSTEM HERMIT <br /> SAN JOA"QUIN COUNTY ENVIRONMENTAL HEALTH .RTMENT 304E WEBER-3""FL-STOCKTON CA 95202 - (209)465-3420 <br /> NON' -REFUNDABLE PERMIT `CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY{/r/j'ZI <br /> CROSS STREET r(P (� A <br /> A APN /—/ f N/� PARCEL SIZE �^ <br /> J57V`7' " <br /> OWNER NAME PHONE <br /> / <br /> OWNER ADDRESS M '�h C,In /�7. �`� CITY/STATE/ZIP <br /> CONTRACTOR / lkF^I C�Ai/0 PHONE <br /> 5q 7zWA ` Y <br /> CONTRACTOR ADDRESS "' � A-Of CITY/STATE/ZIP r�" f Y f A <br /> A� <br /> LICENSE ❑C42 ❑C-36 OTHE0. A — LI tl 7 NUMBER—&'� �2dy/ EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: NEWINSTALLATION LIREPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ PREPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER --- <br /> NUMBER OF LIVING UNITS: N UMBER OF BEDROOMS: NUMBER OF EMPLOYEES: zr <br /> G <br /> 1 <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY Sal #OF COMPARTMENTS <br /> I GREASE TRAP TYPF/MFG CAPACITY A� '/ gel #OF COMPARTMENTS <br /> Q WG TX PANT DISTANCE TO NEAREST: WELL /moi'A ft FOUNDATION ft PROPERTY LINE <br /> ❑ LIFT ft <br /> �J J <br /> FT TATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> Cl LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATIONft PROPERTY LANE ft <br /> FILTER BED WIDTH �ft LENGTH y ft_., DEPTH .JO ft <br /> j"elzQ?), DISTANCE TO NEAREST WELL H FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 /> IN�I�M(tJ�M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIO�NJS—PLEA/SE CALL(209)953-7697 <br /> SIGNED �• �`^�{ TITLE �` - d-c.*2Y-✓ DATE_L' lU <br /> J <br /> 1 <br /> L l L- A 0 <br /> 0 <br /> 1 M NT <br /> DEPARTNT <br /> TUSE�ONLY- <br /> ME <br /> Application Accepted By �~ Date Area ^'r Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS .[�j���/ ✓{' `�iie�i �17� � <br /> PE SC Received tNftk#1 Amount Data PermiV Invoice# Permit ID# <br /> Code INPo By Cash Remitted Service Request# <br /> V, <br /> 42-01-001 <br /> .12/2/02 ONSITE WAS PERMIT <br />