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�l. ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTV ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -309 FL-STOCKTON CA 35202 - (209)46$-3420 <br /> NON-REFUNDABLE PERMIT CALL `2.09 953-7697 FOR INSPECTIONS EXPIRf4§ 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS {.L L� fTLJ C- CITY <br /> /ZIP rr� <br /> CROSS STREET APN PARCEL SIZE / <br /> v <br /> a <br /> OWNER NAME 9'V • �� �! PI{OrvE <br /> OWNER ADDRESS L CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ FERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRJADDITION ❑ ENGINEER DESIGNED oi�/ALTERNATIVE. <br /> CJ REPLACEMENT DESTRUCTIONnaSg42:6 4, <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: dl�{f'F�cYy <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS r� ' <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> `.�a ,I <br /> LIFT STATION SIZE TYPE OF PUMP �'� �y �qjw � w AN> I1.NE'P,1R. N L4SED SYSTEM) [J- <br /> R a 11 <br /> ❑ LEACH LINES U LEACHING CHAMBERS �'�f�p l �e <br /> DISTANCE TO NEAREST WELL ft FOUN AT[ON 1 i 111,E (�� P •LT! <br /> ❑ FILTER BED WIDTH ft LENGTH ; 'oei�et"E7EP{T>jt���1i� �l'�� tt <br /> DISTANCE TO NEAREST WELL ft FOUI1IQI�TIOD�9�yimPr .dA Neal % &TAWH ft � 1 <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS W11)TH 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 WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24'HOjU3�4DVAANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 �y <br /> SIGNED ��Ti'�[a A✓l�� / l �✓� S TITLE Y _X_A DATE � ; f ?! � <br /> �`���, •fie/ . <br /> ; 1 <br /> -�! <br /> I <br /> SAN,OA u <br /> ENVIRONME I L <br /> Als t O+�•" <br /> J. <br /> DEPARTMENT USEO LY <br /> Application Accepted Da Area Employee ID# <br /> Final Inspection Bty ' Date L L ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De h of 3 Ft: PiUS mp Soil Character: _ <br /> COMMENTSej 41 <br /> CC. <br /> PE SC Received C Am unt Permit! <br /> Code INFO B Cash Remitted Date Scrvicc Request <br /> # Invoice# Permit ID# <br /> 7-4i,u Fir--Vd-y Uk;5pi12:7.gQ7 x-iC i4o L2-_ ONSIDE WASTEWATER PERMIT <br /> 12122/2003 <br />