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' ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXP ES 4,,YEAR FROM DATE ISSUED <br /> JOB ADDRESS l CITY/ZIP <br /> �1 ,( <br /> CROSS STREET l - APN 1C, �7 ��J Q —14--PARCEL SIZE <br /> t O <br /> OWNER NAME: PHONE <br /> /r ,( q rte <br /> OWNER ADDRESS 'i ` 2 .}�(/� CITt'1STwTFJZIP y (/ / 1 y� <br /> u <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # Z BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/AL7 ATIVE <br /> F ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPFJNIFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETO NEAREST: WELL ft FOUNDATION ft PROPERTY LME R \.1 <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) Vim' <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft l� <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <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 R DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl (0 <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH fl 1 <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft 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 /> ORDINANCES,STATE LAWS AND RULES.AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIM1tU24 HOUR ADVANCE NOTICE EQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE G�(�. � DATE ''5 <br /> 1 <br /> wm• o <br /> 10�7 <br /> IOU� <br /> L <br /> NORWW O <br /> - �- C11o M 6 <br /> S <br /> EPARTMENT USE L_l' --� y� <br /> Application Accepted ey / .Area �/( Employee ID# Y< Ar C� <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by / T <br /> Character of Soil to Depth <br /> /Iof 3 Ft: Pit]Sumn Soil Character: <br /> COMMENTS j i 1 dY1 tt Ct4_ ZIA., <br /> PE SC Received hec Amount al Per Invoice# Permit ID# <br /> Code INFO g ash Remitted Service Re uest# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />