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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTALHEALTH DEPARTMENT 304E WEBER AVE-3`°Fl,-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT^^ p�CALL(209)953-7697 FOR INSPECTIONS E�X'PIRES 1 yYEAR FR <br /> OM DATE ISSUED <br /> JOB ADDRESS -f-`• 7 C• "� �S'^- CITY/Z!P <br /> CROSS STREET APN,� "" " PARCEL SIZE <br /> OWNER NAME. KI•'�A'�� `'�� PHONE 2D <br /> ( <br /> OWNER ADDRESS ]'� P �•�{.�K ��'�^� CIiY/STATFIZIP li4 I L�L-U+,'c-C..E�j f q <br /> CONTRACFOR v PHONE T— <br /> CONTRACTOR ADDRESS CITY/STATE/Z•lP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH:_ R GEOGRAPHICALINFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BU1LD[NC PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADOFTION ❑ ENCINEERDESIGNED/A1n'FERNATIVF <br /> ❑ REPLACEMENT DESTRUCTION `�EP'rI�7`y1W <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER_ <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG— CAPACITY gal #OF COMPARTMENTS__ - <br /> GREASE TRAP TYPF.IMFG CAPACITY yal #OF COMPARTMENTS_4 <br /> O PKG TX PLANT DISrANCETO NEAREST: WELL R FOUNDATION R PROPERTY LINE K <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENcLoscD SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R <br /> DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE R <br /> ❑ FILTER BED WIDTH R LExam R DEPTH A <br /> DISTANCE TO NEAREST WELL n FOUNDATION R PROPERTY LME R <br /> Q MOUNDED WIDTH R LENGTH R DEPTH _ R <br /> DISTANCE TO NEAREST WELL_ R FOUNDATION_ R PROPERTY LINE R <br /> ❑ SUMPS WIDTH R LENGTH R DEPTH R <br /> DISTANCETO NEAREST WELL Fl FOUNDATION 11 PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH fl <br /> DISTANCE TO NEAREST WELL _ R FOUNDATION R PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH fl <br /> DISFANCETONEAREST WELL R FOUNDATION It PROPERTY LINE R - <br /> I HEREBY CERTIFY THAPY&AVE,,VREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> NANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-.P/LEASE CALL(209)953.7697 / <br /> SIGNED TITLE VG�/"tC- — DATE�I/! <br /> '--' -� <br /> ti <br /> I ENT <br /> �PARTMENTUS NLV <br /> Application Accepted By f . Date t Atea 1� Employer[DO / <br /> Final Inspection By bate.�" 5 ❑ SPECIALPERMIT-Approvedby /1 <br /> Character of SoR to Depth of 3 Ft: _ �USump Soil CharacteJr; <br /> COMMENTS elw <br /> I i <br /> PE SC Received Checldl/ Amount Date PermlU Invoice# Permit IDS <br /> Code INF() $ Cash Remitted Servlce ueN# <br /> `f 22 0 7 I't- 7 I a 0 , <br /> I <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br />