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/V -VV <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPAR1.kHENT S 304 E WEBER AVE -3"Fl, -STOCKTON CA 95202-(209)4(15-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />�gy <br />JOB ADDRESS G �//��'1L.�r+✓r �r c n�G r� 2 Cj CRrYC3!��� <br />1/ZIP Q.� <br />CROSS STREET P -Ft (I u -f' C APN / fV PARCEL SIZEy o <br />g Z <br />OWNER NAME h Y /� /moi f PHONE <br />OWNER ADDRESS r' V1 -G- CITY/STATE/LIP <br />CONTRACTOR i - r! C C- PHONE <br />i CONTRACTOR ADDRESSO S' CITYISTATEIZIP 141 <br />LICENSE ❑ C42 ❑ C-36 OTHER _ NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: fl GEOGRAPHICALINFOR.MATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION Ir REPALR/ADDITION O ENGINEER DESIGNED/ALTERNATIVE <br />❑ REPLACEMENT D DESTRUCTION <br />INSTALLATION WILL SERVE: "ESIDENCE ❑ COMMERCIAL ❑ OTHER <br />:NUMBER OF LIVING UNITS:_ I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />❑ PKG TX PLANT <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION R PROPERTY LINE _ ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />all LEACH LINES ❑ LEACHING CHAMBERSma�yy..,� I OF LINES LENGTH OF LINES L401_ ft <br />DISTANCE TO NEAREST WELL SVI ft FOUNDATION %O / R PROPERTY LINE Lam/ ft <br />❑ FILTER BED WIDTH ft LENGTH ft DEPTH fl <br />DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br />❑ MOUNDED WIDTH ft LENGTH It DEPTH it <br />DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br />IlY SUMPS WIDTH ot- ft LENGTH �a 1 fl DEPTH jL11 ft <br />DISTANCE TO NEAREST WELL 4 0' It FOUNDATION IIS) ft PROPERTY LINE Jb ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH R 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 R FOUNDATION ft 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 LAW'S AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 1 V-IjLi� TITLE G" )L-rc—to (I DATE �� 6 <br />ccepted B - <br />Application Accepted" <br />DEPARTMENT US NL ' <br />Date 2 Arca_ <br />Employee ID# <br />Final Inspection ByDate <br />O [I SPECIAL PERMIT - Approved by <br />Character or Soil to Depth Dr 3 Ft: <br />Pit/Sump Soil Character: <br />COMMENTS <br />% <br />_ <br />PE,SC Received <br />Check# <br />Amount Date Permit! <br />Invoice # Permit [D# <br />CoINFO B <br />Cash <br />Remitted Service Request # <br />1 a' <br />42-02-001 <br />ONSITE WASTEWATER PERMIT <br />12222003 <br />