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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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP '1 <br /> CROSS STREET N1 %J� Cif APN G0!5---Z60 PARCEL SIZE D <br /> TTT---TTTv <br /> ,t v <br /> OWNER NAME wIa yiz 5. (, . :1/�r� PHONE <br /> OWNERADDRESS -5 4Js,-1` CITY/STATMIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-02 ❑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 ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <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 TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETO NEAREST: WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft m <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH it LENGTH ft DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft —� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it 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 ft FOUNDATION It PROPERTY LINE fl <br /> ❑ SEEPAGE PITS NUMBER WIDTH fl DEPTH ft <br /> DISTANCE TO NEAREST WELL R 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(209)953-7697 1 s, <br /> SIGNED- 2 V----TeLE T � � DATE t L <br /> Av <br /> au oN <br /> El, iS ON OE,41 <br /> I H H E <br /> - -RPARTME T 3 - ---- —'- - -- <br /> Application Accepte Date Area Employee I <br /> Final Inspection B ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 t: Pit/Sump Soil Chancier: <br /> COMMENTS ��3/c�- ���;s� its ✓i;rrFr� T/7/I cY�:Ea �Irio.-� c�,�. �.� J <br /> yy- i'�.J � _i gip.,' - �evarrr�it;rs -s_Lj J ��i!.•++1� �i�.riC �GIa..J <br /> PE 9C Received Chet"/ Amount Date Permit/ Invoice# Permit IDN <br /> Code INFO By ash Remitted Service Request N <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />