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Pry) 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-REFUNDABI,E P IT CALL(209 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> !. <br /> JOB ADDRESS A)• nCITU/Z�I <br /> Pb <br /> CROSS STREETVj /^' <br /> L�� • I • '� PARCEL SIZE •y`' o <br /> .APN� �-�—+r-- <br /> u T �32_07rt Pz_ 4�-C �. <br /> �3= >2 <br /> DINNER NAME PHOSrOE,� /fes <br /> OWNER ADDRESS �[ L N �`•" — CITYISTATE/ZIP—ti J A <br /> DA, A !1 itwc / <br /> /�� PHONE <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE C42 ❑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 REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMYtERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTME STS <br /> Cl GREASE TRAP TYPEiMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION_ ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP�i ❑ STAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES )8C LEACHING CHAMBERS� Vmoi,v #OF LINES ! LENGTH OF LINES 4 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION COO PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH 0 DEPTH ft W <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE <br /> ❑ MOUNDED WIDTH it LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH <br /> 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 is WELL ft FOUNDATIO Ili PROPERTY LINE ft <br /> XSEEPAGE PITS NUMBER L WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL .t R FOUNDATION _ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS ORDINANCES,STATE LAWS AND IRULES AND REGULATION AND THE WORK ONS OF SAN LL BE EWITH SAN JOAQUIN COUNTY <br /> JOAQUIN COUNTY. <br /> SIGNED` MIN Nl M1 E )TICE REQIIRED FOR INSP I h'S-PL 209)953 7 <br /> 1(J❑� TITLE DATE <br /> r <br /> E Q <br /> C k f N <br /> DEPARTMENT U, <br /> 5F <br /> 01 Y S � <br /> Application Accept _ Date r �--3 G.6 Area Employee ID# / 92 <br /> Final inspection � �` � � Date � �� � ❑ SPECIAL PERMIT-Approved by <br /> Character of Sol]to th of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS ; ry =''•d'�BnB�tr r €���4` p` `� cTo F iCo � <br /> PE SC Received ChecW!! Amount Date Permit/ Involce# Permit ID# <br /> Code INFO BY Remitted Service R nest M <br /> 142 .15 2sI O ) <br /> ONSITE WASTEWATER PERMIT <br /> 42-02-001 , <br /> 12222003 <br />