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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 M T CALL 2 953-7697 FO INSPECTIONS FIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS _5"JA 5 LISO CITY/ZIP <br /> JI AP4/ / -�3 PARCEL eCROSS STREET Al^ Iv <br /> OWNER NAME <br /> PHONE <br /> OWNERADDRESS 3 - GrJso`a SOrL/ CITY/STATFJZIP�/Y� <br /> CONTRACTOR ✓ 6 N PHONE 3 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE •42 ❑C-36 OTHER NUMBER EXPIRATION DATE D \ <br /> WATER TABLE DEPTH: ft GEOGRAPHICALINFORMATION: Coordinates X Y <br /> E3 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# f f <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENGE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBE.R,rOF BEDROOMS: � 1NUMBEROFEMPLOYEES: <br /> SEPTIC TANK TYPFJMFG �1! �WE'c' CAPACITY I.a;10 gal #OF COMPARTMENT'SO _ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY - gal #OFCOMPARTMENTS O <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL FOUNDATION ft PROPERTY LINE Z ft <br /> :3 LIFT STATION 512E TYPE MP D OI SEPARATOR(ENCLOSED SYSTEM) <br /> 01 LEACH LINES LEACHING CHAMBERS #OF LINES .11— LENGTH OF LINES glo ft <br /> DISTANCE TO NEAREST WELL (17 ft FOUNDATIONJO ft PROPERTY LINE /'0 ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE, ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL �ft2 FOUNDATION ft PROPERTY <br /> LINE ft <br /> v� SEEPAGE PITS NUMBERWIDTH �) ft DEPTH t7C.� ft <br /> DISTANCE TON REST WELL FOUNDATION f PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I 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 /> (. MIN�24HQDVANCE NOTIC'REQUIRED FOR fNSPE IONS-PLEASE CALL(209)953-7697 <br /> Of <br /> SIGNED s'p t�TITLE DATES d <br /> A w <br /> H E <br /> —Zr <br /> I <br /> 4 4- <br /> DEPARTMENT SE LV <br /> Application Aceept j�may`F��11— Date Area Employee ID# <br /> Final lnspe�tion y - •.'t Datc ✓� .' E3 SPECIAL <br /> PERMIT-Approved by <br /> Character of Soil to pth of 3 t: Pit/Sump Soil Character: <br /> COMMENTS NAL-1 L&r - <br /> /'_y,"•L� <br /> PESC Received Checldfl Amount Permit/ _ <br /> Code INFO BY— Remitted Date Service Request# :1)BvoHle# ; PermiJ <br /> - J=am t,_ <br /> t3 b o <br /> � <br /> 3 <br /> i <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/2212003 - <br />