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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-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR MMP4TE <br /> ISSUED <br /> JOB ADDRESS beCITY/ZIP Prey <br /> /J GJ en <br /> CROSS STREET APN ... � (/ / PARCEL SIZE 362p <br /> n C <br /> OWNER NAME 'Y C C PHONE 010 9- <br /> OWNER ADDRESS CITY/STATEIZIP <br /> I ` <br /> CONTRACTOR / N ev / PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> l <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE N <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ FERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> j ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES e�SV� ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> F D FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> t <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> S DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> PI BE IDT EP <br /> IAN NE WELL. TION PR RTY r <br /> HERESY CE IFY T I VE PA D 1S APP ATIQN AND E WpRK W BE NPACC0%AN W H SANQ COUNTYRDI NC S ND RULES NS OFU V. <br /> M ,1"�1 UM Hg1LR.AD ANS N TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> SIGNEDPTITLE DATE <br /> At OOF <br /> N. <br /> i <br /> I <br /> DEPARTMENT SE Y' <br /> Application Accepted B Date Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS G1,11) W CftagQ, <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By JRemitted �} Service <br /> +Re uest# <br /> ` <br /> S UO U "1 log M <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />