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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 u CA L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS s C[TYIZIP 3 <br /> 1 � i <br /> APN <br /> CROSS STREET CA� PARCEL SIZE e 1 <br /> . PHONE✓�� f [ .�' r <br /> OWNER NAME <br /> VVI - f'�--y�- <br /> OWNER ADDRESS v <br /> CITY/STATE/ZIP <br /> '^ tt <br /> CONTRACTOR V 1 e , PHONE <br />' - CITYISTATE/ZIP - ' <br /> CONTRACTOR ADDRESS <br /> LICENSE ❑C-42 L3 C-36 OTHER NUMBER EXPIRATION <br /> / DATE <br /> WATER TABLE DEPTH: ' <br /> ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # w BUILDING PERMIT# LAND USE APPLICATION# <br /> C3 ENGINE ER DESIGNED/ALTERNATIVE <br /> TYPE OF WORK: ❑ NEW,INSTALLATION <br /> ❑ REPAIRIADD1T10 <br /> Z1 REPLACEMENT DESTRUCTION <br /> ❑ RESIDENCE L3 COMMERCIAL L3 OTHER <br /> INSTALLATION WILL SERVE: <br /> j NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> NUMBER OFLIVINCI.7NIT5: ' <br /> 9: CAPACITY gal #OF COMPARTMENTS <br /> 4 ❑ SEPTIC TANK TYPE/MFG <br /> 5 CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL <br /> ft FOUNDATION ft PROPERTY LINE ft <br /> k ❑ LIFT STATION SIZE TYPE OF PUMP E3SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> Il ft <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS ft OUNDAT[tlty` xoPI <br /> R 1) <br /> DISTANCE TO NEAREST WELL g ft <br /> ❑ FILTER BED WIDTH ft LENGTH lbave �> r thlll It ft <br /> DISTANCE TO NEAREST WELL ft FOIJND�AfrltO�ly ft� oft rPI[Spec ft' [ y <br /> ❑ MOUNDED WIDTH,r ft LENGTH VV �I(( }�Ij�1JJt�rp,,�#y, �i7�tF' sf1 � <br /> DISTANCE To NEAREST WELL ft FOUNDAfi��JN §�VIrC�nIY�i �.Ld41 Hea# PF�[h�l4ltf on ft O <br /> ft DEPTH ft <br /> [3 sumps WIPTHa ft LENGTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> � ft <br /> ❑ DISPOSAL PONDS WIDT0. ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 'I. EPfR <br /> fi <br /> 51 ER W <br /> DI N NEA ELL FOUNDATION TY LIN ft`IEREBY CE IFYT 1H E A DT SAPPL ATIONAND E WORK W IL NE 1 CCORDANI SA AQU COUNTYST LAW ND RULES A EGULAT! OF J QUIN COU <br /> MINIMUM 24,HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- SE LL(209)953-7697 <br /> I SIGNED TITLE - ATE <br /> �l <br /> J= = s <br /> 416 <br /> 4. <br /> AQ A <br /> �H. ZZ KUP41 <br /> A <br /> T <br /> r DEPARTMENT .E ONLY <br /> Application Accepted B Date « z Area Employee ID# <br /> App Dt <br /> P Y � ffffff <br /> Final Inspection By <br /> I� Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PitlSump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit'11D# <br /> Code INFO B Cash Remitted Service 0--f# <br /> ONSITE WASTEWATER PERMIT <br /> 42-02-001 „ <br /> 12!22/2003 <br />