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ONSITE WASTEWATER TREATAIEN'.1' SYSTEM PERINUT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARFMENT 304 E WEBER AVE -3°" FL- STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDAB R ftalg CALI.(209)53-7697 Fills INSPECTIONS rRif IREpS 1 YEAR FROM DATE ISSUED <br />JOB AD1)RRSS --,UI Q CITY.171 S <br />U' <br />CROSS STREET AP\• ��/ � � /f <br />DISTANCE TO NEAREST <br />�pPAtRCCELNIIZE. t�V v^��Z/ <br />OWNERNAME P/�Io_uE "'?y G7 %w[7 <br />GO <br />OWNERADDRESS �"'�• �� H i�•w 7 4 <br />! CITY/$TATEIZIP <br />WIDTH <br />+y'/ �+ r �e� <br />CONTRACTOR J( 4(e ?N rz-1 'r'��/ ��V� • PHONE Q p <br />ft DEPTH (1 <br />CONTRACTOR ADDRESS _! � } '^ " fyc,.%�l'•'� CITY/STATE/ZIP p OCF[7tiW CA 3� L. r <br />DISTANCE TO NEAREST <br />j/ <br />LICENSE 13C-42 L)C-36 OTHER NUMBER *+' � EXPIRATION DATE '`� (> <br />ft FOUNDATION (t PROPERTY LINE It <br />❑ MOUNDED <br />C� <br />WATER TABLE DEPTH: ft GEOGRAPHICALINFORMATION: Coordinates X Y <br />It DEPTH }) <br />PERC TEST (S) NUMBER LAND USE APPLICATION #V��-,CCyy <br />DisTANCETONEARESF <br />TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br />Y} <br />❑ REPLACEMENT ❑ DESTRUCTION <br />p <br />N <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />O DEPTH (1 <br />NUMBER OFLtviNG UNITS: NUMBER OF BEDROOMS: NUMBEROr EMPLOYEES: <br />I" <br />_ <br />❑ SEPTIC TANK TYPIIMFG CAPACITY gal # OFCOMPARTMENTS <br />ft FOUNDATION Il PROPERTY LINE l <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />WIDTH <br />❑ PKC TX PLANT DISTANCETO NEAREST: WELL ft FOUNDATION -- R PROPERTY LINE <br />P DEPTH jl <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />DISTANCETO NEAREST <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES It <br />DISTANCE TO NEAREST <br />WELL <br />(t FOUNDATION It PROPERTY LINE P <br />❑ FILTER HED <br />WIDTH <br />H LENGTH <br />ft DEPTH (1 <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION (t PROPERTY LINE It <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />It DEPTH }) <br />� <br />DisTANCETONEARESF <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMP$ <br />WIDTD <br />ft LENGTH <br />O DEPTH (1 <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION Il PROPERTY LINE l <br />❑ DIS POSAL PONDS <br />WIDTH <br />it LENGTH <br />P DEPTH jl <br />DISTANCETO NEAREST <br />WE13. <br />_ <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />WIDTH <br />ft LENGTH <br />fl DEPTH fi <br />DISTANCE TO NEAREST <br />WELL <br />R FOUNDATION ft PROPERTY LINE ft <br />I HEREBY CE PV THAT <br />1 HAV PREPA THIS AP LICATION AND THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STAT <br />WS AND RULES ANDRECULATIONS OF SAN JOAQUIN COUNTY. <br />I IM 24 HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209) 953-7697 <br />SIGNED <br />TITLE 'F.{(tdrAi�E-E'� �J �� <br />DATE T <br />Application Accepted By <br />Final Inspection By_ <br />Character of Soil to Dept <br />COMMENTS " <br />Ft: <br />1 <br />EO• Ll' �Ia <br />Area Employee [D# <br />❑ SPECIAL PERMIT -Approved by <br />Pit/Sump Sail Character: <br />C Y r 5-r <br />42 -DI -001 <br />122'02 ONSITE WASTEWATER PERMIT <br />PE <br />SC <br />Received Amount <br />Permit/ <br />Code <br />INro <br />• <br />B Cash Remitted <br />ate <br />Service Request # <br />Invoice # PermillD# <br />��' <br />� <br />� 1 / <br />J•, f <br />37b b <br />� <br />42 -DI -001 <br />122'02 ONSITE WASTEWATER PERMIT <br />