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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-341 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 K,. �n ^ CITY/ZIP P <br /> CROSS STREET - IV. Uc�l �'��J APN a8y--lye-�� PARCELSIZE �CY� p <br /> of <br /> OWNER NAME Tim' Ll.. (_ra-t�Lkl IIT RI(J1 f LA (r YA,k)LPHONE <br /> P� A <br /> C <br /> OWNERADDRESS CITY/S ATE/LI <br /> CONTRACTOR Nr I I n,Ani �udT C' PHONE <br /> CONTRACTOR ADDRESS (J 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# c <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ENGINEER DESIGNED/ALTRNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> 1 <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFO CAPACITY gal #OF COMPARTMENTS �+ <br /> ❑ CREASE TRAP TYPE/MFG CAPACITY, gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION it 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 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R "� <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It; <br /> DISTANCE TO NEAREST WELL -ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br /> DISTANCE To NEAREST WELL ft FOUNDATION it PROPERTY LINE R <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION A D THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUI COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. I ,•�• - < <br /> IINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> . r /� � <br /> SICNE - TITLECQa=[C2j ��1 DATE <br /> M <br /> 4 Am <br /> Ll <br /> 1 <br /> O <br /> /q N <br /> EP R <br /> DEPARTMENT USE LY <br /> Application Accepted By i Date Area f Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received eck# Amount Date Permit/ Invoice# PermitID# <br /> Code INFO By ash Remitted Servl a Re uest# <br /> 42.02.001 ONSITE WASTEWATI PBRMIT <br /> 12/22/2003 <br />