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t <br /> r ONSITE WASTEWATER T ATMENT SYSTEM PERMIT SCANNED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NOR-REFUNDABLE'P I MIT CAKL 209953 CITY/Zip-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUED <br /> L <br /> JOB ADDRESS i LIA- S <br /> CROSS STREET M a/N IES APN I✓l� ( / [J 3PARCEL SIZE 1 2 7 p <br /> OWNER NAME -- ' I ` /PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP 1�_ i <br /> ` <br /> CONTRACTOR In PHONE <br /> � { <br /> I <br /> I <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE ❑C-42LJC-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: Q NEW INSTALLATION ❑ REPAIRIADDIT ON ❑ ENGINEER DESIGNED/ALTERNATIVE S <br /> ❑ REPLACEMENT DESTRUCTION <br /> i <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 TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> i <br /> ❑ 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 /> i <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft 4 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft r} <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> 0 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft r! <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY rl <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-Pill CALL(269)953-7697 <br /> I Q <br /> SIGNED TITLE ATE f <br /> Jyq <br /> R <br /> l d <br /> r N NIF uv f <br /> JI <br /> 4 Sv — <br /> /I Azltupq- <br /> 9 <br /> 1 <br /> ATL j <br /> til HF- I <br /> f <br /> DEPARTMENT tjSE ONLY <br /> 4� - Date �r Z� Area oZ� f Employee lD# <br /> Application Accepted By <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS S,CP kc-'"e <br /> PE SC Received heck# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> 1+7- 0-7S (XI 3-7 ry oo 02 oo` u(N2- Z4,9'2 (3 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12122/2003 <br />