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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"P FI.-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REWNDABLErPERMIIT CAI 1. 209 9553-7697 FOR INSPECTIONS EXPIR S I YEAR FROMDATEISSUED <br /> JOB ADDRESS J !/ S ' pe A` CIITTY/ZIP ^' 2'11119, ` <br /> CROSSSTREET A P N 105'6 1lO PARCEL SIZE /,r`- D <br /> OWNERNAME / f7 IY/I ��/t� PHONE. p? <br /> OWNER ADDRESS S••r CITY/STATI/Z1P ' ell/, <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATF/ZIP <br /> LICENSE 0C42 L3 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GF.OGRAPHICALINFORMATION: Coordinates X Y <br /> ❑ PERC TEST #__ BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIWADDII'ION U ENGINELRDISICNED/ALTERNATIVE <br /> ❑ REPLACEMENT _ ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPI.DYF.FS: <br /> ASEPTIC TANK TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETO NEAREST: WELL ft FOCNDATION ft PROPERTY LINE. It <br /> ❑ LIFT STATION SIZE 7VPEOF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> j1L LEACH LINES ❑ LEACHING CHAMBERS #OF LINES J LENGTH OF LINES �(/rV R <br /> DISTANCE.TO NEAREST WELL ,fog ft FOUNDATION 140P4119 / ft PROPERTY LME I <br /> ❑ FILTER BED WIDTH __ ft LENGTH ft DEPTH It �\ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ,`•' <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH Il DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH Fl DEPTH ft <br /> DISTANCE TO NEAREST WELL fl FOUNDATION _ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER __WmTH_ _ A DEPTH _ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION D PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> O WINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY: <br /> �{� MIN,I�M. t HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �'v+i-�Ji TITLE V' �. DATE J '2 <br /> �- ` r+srni•e rs•• <br /> 50 p OISTnA' �''/ <br /> upyyry� N d. <br /> M.—M.- 400]CN. / <br /> R TNIR <br /> vnln aD•vc r4 PfE <br /> 4.3 4PI. COXKLf vAA•Ev,PIPC <br /> PAY Mf <br /> R CEI' <br /> .s�.R.•05 Q):RM�4. — — — — — — —❑ OCT 1 i. <br /> WT—as0".12.3NV. <br /> abl. <br /> 0 PIPE <br /> SANJOAOUI <br /> ENVIRON <br /> N;.fMI Tar IrnOn ura(}rP) T �r4:r <br /> I4.la W. HEALTH DEI <br /> L- 01IIILi, <br /> T. <br /> NIET.,1.03 NV. <br /> Bt.o .i•j; / ' <br /> {GT <br /> ' <br /> MIS <br /> nEtEN WENe1L Y T <br /> -1. <br /> 4•PRTED IPF <br /> 3■ No.25835 <br /> g .:.:;. Exp.12-31-05 <br /> y oc C A iFUP\,\� <br /> • �PJCnL DISPOSAL TRENCH _ <br /> D71FARTMENT USE ONLY <br /> I <br /> Application Acce Date 7i Arca � Employee IDN <br /> Final Inspecti By Date ����d C/ ❑ SPECIAL PERMIT-Approved by v <br /> Character DISoI o Deplh oF3 [: Pit/Sump Sail Character: ` <br /> COMMENTSw,,"54 <br /> PE SC Received heck#! Amount Date Permit/ Invoice# P�r D# <br /> Code INFO B y E I Remitted Service Re!:U # <br /> a, ! <br /> 5730 Z.Z— .3-v !o 0 <br /> 62O03 wS <br /> 42-02-001 ONSITE WASTEWATER PERM IT <br /> 12/22/2003 <br />