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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 EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP < w <br /> CROSS STREET /�I D UC / ¢� A`APN PARCEELL SIZE o <br /> /OWNER NAME �� ,�S ( Sc- PHONE / ^ l0,4y w <br /> OWNERADDRESS gbrs-�, CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION Cl REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT (3 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS CT <br /> cA <br /> ❑ PKG TX PLANT DISTANCE To NEAREST: WELL ft FOUNDATION R PROPERTY LME <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R m <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH_ft LENGTH ft DEPTH ft -4- <br /> DISTANCE TONEAREST WELL R FOUNDATION ft PROPERTY LINE fl T <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH ft (2`\ <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> 1 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL f209)953_7697 <br /> SIGNED eLE � s���.).... DATE �o• �rL° C <br /> V— J11114 1 40 (111 <br /> D1 LIT- <br /> EN V <br /> E I N VE <br /> H H DETRIM <br /> -HPARTME T SE WY <br /> Application Accepte Date Area Employee I W <br /> Final Inspection Date i ❑ SPECIAL PERMIT-Approved by <br /> I Character of Soil to Depth of 3 t: Pit/Sump Soil Character: <br /> COMMENTS <br /> 71'1 1+10-12 -s_-irF•i <br /> 9PE C Received Check#/ Amount Date Permit/ Invoice# PermitlD# <br /> de INFO B Cash Remitted Service Request# <br /> 2 arl tJ` 6 ab <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 121222003 <br />