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I <br /> 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-REFUNDAB E7EMffgg� LL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DAT ISSUED <br /> JOa ADDRFSS CITYILIP A <br /> PARCEL SIZES > <br /> CROSS STREET J�1 (� ,+ =-2 <br /> ` PN S <br /> OWNER NAME {e�I•�/�) 4 .A/ ZZ—�3 t� L'HONE 43 <br /> OWNER ADDRE.4S Pin CITYlSTATFJ2;IP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYlS�I'ATEIZIP <br /> LICENSE C-02 Q C-36 OTHER I A I NUMBER EXPIRATION DATE_1 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST #_ BUILDING PERMIT#__._ LAND USE APPLICATION 1F <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION ❑ ENGINEER DESIGNEDIALTER2IATIVE <br /> Q REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL -❑ OTHER, <br /> NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS= NUMEER OP E!HPLOYEES: <br /> ❑ SEPTICTANK TY"J.MFC_-- _ _ CAPACITY pp'. #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPENFO__.._ CAPACITY P1 #OFCOMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION _ ft PROPERTY LME ft <br /> ❑ LIFT STATION S17.E TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES )d LEACHING CHAMBERS150 • 6 I moi-#OF LINES LENGTH OF LINES 60 ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION_ ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH _ft LENGTH _ft DEPTs ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WmrR ft LSNGTH _—R DEPTH ft 9 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ SUMPS WIDTH ft LENGTH _R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft L.ENC M_ ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> SEEPAGE PITS Ncslaea WIDTH ft DEPn+ ft <br /> DISTANCE TO NEAREL'T WELL ft FOUNDATION + R PROPERTY LINE R <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY I <br /> ORDINANCES,STATE LAWS AND RULES AND RfGVLATtONS OF,SAN JOAQUIN COUNTY. <br /> MINIJ UM 24 NOTICE REQUIRED FOR I C LL(209)953-7697 I l` <br /> SIGNED i lHi�$ <br /> 4- 11 iiXi <br /> o i Pc I SRs �I e I I <br /> 8 &a - <br /> 1• <br /> ill a 1 � v y �3!• i � <br /> •p 0 _ I '. � e c a <br /> �B s$I" 13 <br /> 3I� <br /> !I i Hill i 47t <br /> o - <br /> ( __�_ �9 <br /> Application Acceptad By ! Date A <br /> /�!_G Employee II,4t � <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Characterol'Soil to Dep aF3 Ft: PI um Soil Character. <br /> COMMENTS 0t...r3 "-r D <br /> PE SC Received cc Amount Permit/ Involce 0 Permit IDN <br /> Code INFO B Cash Remitted Pate Service Request# <br /> fz.Iy Tis <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12,22)2003 <br />