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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT `S <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"FL-STOCKTON CA 95202 - (209)458-3420 <br /> NON-REFUNDABLE PERMIT CALL.(2099)953-7697 FOR INSPECTIONS EXPIRES`I YEAR FROM DATE ISSUED <br /> JOB ADDRESS �' / b)iit�/ ,��,I- CITY/ZIP <br /> CROSS STREETxel APN '� PARCEL SIZE /J L/ � �� V <br /> l� PHONEr �+ <br /> OWNER NAME - <br /> OWNER ADDRESS <br /> CITY/STATE/ZIP <br /> PHONE <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS '1 CITYISTATEIZIP <br /> if <br /> LICENSE ❑C-42 ❑C-36 ER 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 E3REPAIRIADDITION L3 ENGINEER DESIGNED/ALTERNATIVE <br /> k <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 /> ❑ PKC TX PLANT DISTANCE TO NEAREST:.WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP OIL E E OS D YSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #, LENGT OF NES, ft <br /> Pf�l��ve ex ICe�wi <br /> DISTANCE TO NEAREST WELL ft FOUNVDDr/ApTIQ- _+ ,ygy�A ft OPERTYLINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ""AK l-11 �<<'� "��I!or inspected <br /> DISTANCE TO NEAREST WELL ft FOUNDATE�f <br /> k ❑ MOUNDED WIDTH tl LENGTH .f ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft y J <br /> l ❑ SUMPS WIDTH - ft LENGTH ft DEPTH ft f^ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft V J <br /> ❑ 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 ft FOUNDATION ft PROPERTY LINE R <br /> 1 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 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 t/ <br /> SIGNED �1Gam' t, � _ TITLE DATE L 02Z �5� <br /> r7- l <br /> s r N eJ,4 II <br /> a <br /> SD:r 12n <br /> 14- M <br /> i VED <br /> 5° 4�X k /�•�or�r u i li:�!f N q .1 A 1-1 111 C u <br /> R MI IVT <br /> + ' <br /> DEPARTMENT USF O 'LY` <br /> f Application Accept y Date Area Zf Employee ID# <br /> Final Inspection Date ... / ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to pth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS Su3 � Gc;��E��D.il . /�/c�_ r2cGt' C�r.� /J S OiJ EG�s-c 1T <br /> i PE SC Received Ch-k#1 Amount Date Permit/ Invoice# Permit ID# <br /> Code INI:O By CA—SERemitted Service Request# <br /> 1 412- 07S 1 Osie 0,6q <br /> 42.02_001 --11�IlG ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />