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L_ ONSITE WASTEWATER TREATMENT SYSTEM PERMIT c WA 95202 :D9><683a28 <br /> —SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE 3"FL-STOCKTON NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �'7�/• P.(, CITY/ZIP , ^I^Y C• - vi <br /> JOB ADDRESS <br /> CROSS STREET N2!4 <br /> 4 APN �—�-'�l D' U9 PARCEL SIZE C� y <br /> OWNERNAME 1• \UVJ ` ` �- PHONE y <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> PHONE <br /> CONTRACTOR C 12 <br /> D T Ta t <br /> rCONTRACTOR ADDRESS p � � 11 �' CITYISTATEIZIP <br /> K% 1IVy <br /> LICFNSE ❑C42 ❑C-36 OTHER NUMBER O EXPIRATION DATE \ 'L <br /> _WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# - ' LAND USE APPLICATION M <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT C3 <br /> C3DESTRUCTION ` II <br /> INSTALLATION WILL SERVE: 12E-RESIDENCE ❑ COMMERCIAL � }�' ❑ OTHER <br /> NUMBER OF LIVING UNITS :_ �_/ <br /> , NUMBER OF BEDROOMS: — NUMBER OF EMPLOYEES: }L <br /> r <br /> SEPTIC TANK TYPE/MFG C •Q CAPACITY P �I V gal #OFCOMPARTMENTS (`\ <br /> ❑ CREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> L❑ PKG TX PLANT DISTANCE TO NEAREST: WELL It FOUNDATION ft PROPERTY LINE fl <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND)OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 41 LEACH LINES ❑ LEACHING CHAMBERS #OF LINES l[Y o2 LENGTH OF LINES <br /> ` DISTANCE TO NEARESTWELL �a� R FOUNDATION �.� ft PROPERTY LINE I�Z M-1-f ft <br /> - ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> —❑ MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> `❑ DISPOSAL PONDS WIDTH ft LENGTH H DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION H PROPERTY LINE ft <br /> CL SEEPAGE PITS NUMBER a _WIDTH LVA <br /> ft DEPTH LIS- <br /> DISTANCE <br /> ISDISTANCE TO NEAREST WELL ,L') ft FOUNDATION 7d fl PROPERTY LINE YI Z YY..1-P fl <br /> I HEREBY CERTIFY THAT 1 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 /> INI`MUM HOUR D ANC N i��jE'R�EQ/I1�I RED FOR INSPECTI{�(�N\S-PLEASE CALL(209)953-7697 V <br /> SIGNED V` 1 v��' TITLE ay�y, "�� DATE O r ­`Js <br /> 17 11\ <br />�� <br /> E <br /> V <br /> H E lllllf NMI <br /> EPARTMENT USY ONL <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection V '%T' +moi+. Date .J ❑ SPECIAL PERMIT-Approved by j <br /> Character o Soi to 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS ✓ <br /> PE SC Received Check#/ Amo a1E Per U voice# Permit ID# _ <br /> Code INFO By s Remitted Service I nest# <br /> L+3- <br /> 42-02-DDI ONSITE WASTEWATER PERMIT <br /> 12/222003 <br />