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i <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3N°FL-STOCKTON CA 95242 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPE TIONS EXPIRES j YEAR FROM DATE ISSUED <br /> JOB ADDRESS I' - ClTY1ZlP <br /> H i <br /> CROSS STREET t APNO PARCEL SIZE Y <br /> OWNER NAME PHONE � - ! I —3-7SZ <br /> OWNER ADDRESS CITY/STATEIZI.P <br /> CONTRACTOR W L PHONE <br /> l <br /> 28 _ <br /> CONTRACTOR ADDRESS - ChT A <br /> i <br /> i <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER pp X I T <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: •CO <br /> Ih eS I r 1 �� Y_ N <br /> LlPERC TEST # BUILDING PERMIT# w I L <br /> TYPE OF WORK:o, ❑ NEW INSTALLATION ❑ REPAIRIADDITION;y ❑t l KIfER 1C 1Y �LTERNgT E l{N <br /> ❑ REPLACEMENT' ClO'DESTRUCTION ` <br /> I <br /> INSTALLATION WILL SERVE, " Ll RESIDENCE © COMMERCIAL ❑ HER �r 5 <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> it <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS B <br /> ❑ GREASE TRAP a TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL - ftFOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP I ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> • DISTANCE TO NEAREST WELL ft FOUNDATION Ift PROPERTY LINE ft <br /> ❑ -FILTER BED WIDTH ft" LENGTH' ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION "I ft PROPERTY LINE ft <br /> x <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMP$ - WIDTH ft LENGTH- �ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ftOOUNTY <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE i THDIST CE EAR LL ft OUNDATION ft PE Y 11NE1 REBYCER YTH HA P R TH APPLI IONANDT WORK WIL D IN CORDANC1 <br /> IT AN J UIO IN ES, AT AWSA DRULESIO OF S O UIN COUNTMINIMUM 24 HOUR ADVANCE OTICE REQUIRED FOR INSPECTIONS-PLEASECALL(209)953.7697 <br /> SIGNED TITLE DATE <br /> - J <br /> s 1 E_- <br /> � <br /> 14­ <br /> , <br /> 1 <br /> 41. <br /> 1,7 - <br /> I <br /> T c k <br /> F'AYft <br /> yak -� .�' -> '- _ C"] Qr t <br /> y ! 1 E <br /> _.k JUN , <br /> r i _SAN Jt)AQI nl <br /> 7M TV ER r— <br /> I' <br /> DEPARTMENT US IONL, <br /> - — •: <br /> Application Accepted By a Date Area Employee ID# ' <br /> [/ <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved byI <br /> Character of Sail to Deptl of 3 Ft: Pit/Sump_Soil Character: <br /> COMMENTS .6)-t <br /> PE SC Received Chec Amount pate Permit! Invoice# Permit ID# <br /> Code INFO <br /> By Cash Remitted Service Request# <br /> o Y s� <br /> d Q <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12122!2003 1 <br /> 11�, <br />