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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTuo <br /> 304 E WEBER AVE -3 FL-STOCKTON CA 95202 - (204)468-3420 <br /> NON-REFUNDABLE PERMIT I� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> J08 ADDRESS f ^_ CITYIZIP .S_6G 1 C`s j <br /> STREET APN ! 3 "- //c)-33 C a-2- <br /> CROSS �S_ <br /> / PARCEL SIZE.OWNER NAME '( IA [ ! ��rr"��r. 7r x <br /> � /� <br /> PHONE <br /> 7 <br /> OWNER ADDRESS' it a CITYISTATEIZIP,�fQ[_YLTC7�1 <br /> CONTRACTOR I� PHONE <br /> CONTRACTOR ADDRESS .!I <br /> CITYISTATEIZIP <br /> IM <br /> LICENSE ❑C-42 ❑C-30 If� 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 ❑ REPAIR/ADD N ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT D TR,t)CT ONS r. S <br /> INSTALLATION WILL SERVE: " RESIDENCE ❑ COMME �` (Aj <br /> NUMBER OF LIVING UNITS: I� NUMBER OF BEDROOMS: H <br /> NU`mBER OF EMPLOYEES: t. <br /> {� <br /> SEPTIC TANK TYPE/MFGII CAPACITY P{��fi May <br /> ��OF�,M,ve IP TMEN 5 <br /> ❑ <br /> GREASE TRAP TYPE/MFGI� CAPACITY work being, 0 HPARor N��❑ PKG TX PLANT DISTANCEi`TO NEAREST- WELL ft .FOUNDATION by E_-.,yirWim PR,' LINNEift <br /> ❑ LIFT STATION SIZE II TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> II <br /> r DISTANCE TO NEAREST 4F': WELL ft FOUNDATION ft PROPERTY LINE ft r - <br /> v) I' <br /> ❑ FILTER BED WIDTH' I ft LENGTH ft DEPTH ft N <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH I� ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft i <br /> ❑ SUMPS WIDTH �� ft LENGTH ft DEPTH fl }� I <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft V <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> i! <br /> EE S i�. T ft H <br /> DISTq T RES W L ft NDATION ft PR ER LINE <br /> Y <br /> HE EBY CERTIF THA AV' R D IS PLICA ON AND THE ORK WILL B O N A ORDANCE H N JO IN UNTY <br /> RI A S TE WS AN RULES AND N SA N COUNTY. <br /> 0 <br /> MIN , M OUR ADV CE NOTICE REQUIRED FOR INSPECTIONS-PLEA i C L(209)953-7097 <br /> SIGNED TITLE I DATE <br /> Ej Ll <br /> U <br /> d <br /> SAN,OVtp U <br /> A T E <br /> VA I <br /> DEPARTMENT US O Y <br /> L l O ! Area Employee 1D# SCS <br /> Application Accepted By Date <br /> Final Inspection By Date © SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of.3 Ft: Pit/Sump Soil Character: <br /> COMMENTSS c�:M>Jc r'zo�1 �o g L <br /> I I <br /> PE SC Received Amount Permit! <br /> Code INFO 13I� a, Remitted Date. Service Request# Invoice# Permit ID# <br /> _ <br /> 42-02-001 5, ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />