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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3M0 FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT y� CALL(209 953-7697 FOR INSPECTIONS /EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS (J-'�/7to V�1 V I N f G RD. CITV/ZIP LG P <br /> � to <br /> CROSS STREET CE-+21 SA.1 A N R1 APPN? 3- () PARCEL SIZE 11.20 <br /> c <br /> OWNERNAME ��1eS 4 PSE rti OfY ].&1 <br /> OWNER ADDRESS �C...F�)�Y1-l?� CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE. <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMI LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑- STRUCTION <br /> INSTALLATION WILL SERVE: [IF-RESIDENCE ❑ COMMERCI ❑ OTHER <br /> NUMBER OF LIVING UNITS!_____L_ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG P$ L CAPACI gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPAC gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL 15-0 ft FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPEOFPUMP ❑ SAND OIL SEPARATOR(ENCLOSED S)LsTEM) <br /> U(lt ICtL. <br /> LEACH LINES LEACHING CHAMBERS S'FL', -"ITT/L #OF LINE --> LENGTH OF LINES (XI) ft <br /> /DISTANCE TO NEAREST WELL l� ���'1ft FOUNDATION ft PROPERTY LINF. R �� <br /> f� <br /> IL FILTER BED WIDTH__ft LENGTH ft DEPTH <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH _ft DEPTH ft r <br /> DISTANCE TO NEAREST WELL R FOUNDATION it PROPERTY LINE ft C. <br /> ❑ SUMPS WIDTH ft LENGTH fl DEPTH It <br /> DISTANCE TO NEAREST WELL III FOUNDATION ft PROPERTY LINE ft r <br /> ❑ DISPOSAL PONDS WIDTH_ft LENGTH ft DEPTH ft <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE 11 <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> �a <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 /> NCF.NOTICE REQUIRED FOR INSPECTIONS Vy-.,PLLEASE.CA/LL(209)953-76Q7 <br /> SIGNED 11yy1�1) 'FITLE k✓,— ` D -2q <br /> - CJ <br /> L ,� iso iii <br /> a <br /> o <br /> LL <br /> NLj <br /> E VI 10 WJNJXC <br /> T F <br /> DEPARTMENTSE ONLY S <br /> Application Accepted By LJC� Date 7, G(n Area Employee ID# �J <br /> Final inspection B' Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to nth of 3 Ft: Kt/Sump Soil Character: <br /> COMMENTS OL t rT -)P- <br /> PE SC Received bee Amount Permit/ <br /> Code INFO 6 Cash Remitted Date Service Request# invoice# Permit ID# <br /> 42.13 !l L'6 '(.5.0. <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />