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I <br /> 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 1 YEAR FROM DATE ISSUED i <br /> CITY/ZIP r"�/��'/l/'/1/V \\ 41 <br /> JOB ADDRESS ` - 4C� 4 <br /> CROSS STREET APN6-rte!/ 'S V PARCELS Y / v <br /> OWNER NAME PHONE_ <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR ` / PHONE <br /> Y14 <br /> I <br /> CONTRACTOR ADDRESS G `� CITY/STATElZFP <br /> LICENSE ❑C-42 ❑C-35 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 ❑ REPAIPJADDITION (3 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 TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS 9 <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> LJLIFT STATION SIZE p� TYPE OF PUMP il� OIL E os D YSTEM) <br /> t . <br /> aL=LI,.j <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS"' # s LENGTH.OF NES. ft <br /> r�l �ve exorred without <br /> i <br /> DISTANCE TO NEAREST WELL ft FOUNDATIO. ft OPERTY LINE ft 1 A <br /> ❑ FILTER BED WIDTH ' ft LENGTH1 �r <br /> - W <br /> DISTANCE TO NEAREST WELL ft FOUNDATI©�lJ'1 ".YifLf Y ft <br /> El 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 /> 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 fZ <br /> f $ 1TRTHIE <br /> R PIRDANC[Mwl <br /> PT r <br /> C EA ELL FOUNDATION TY LINE ft <br /> EREBY CEA AR T APPL TION AND WORK WIL E SAN QU COUNTYDI E TA LAWS D RULES A TS OF UN <br /> �� MINIMUM 24� ��E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DATE <br /> SIGNED �� �� —,%�G �� <br /> N elAIie <br /> a � <br /> i <br /> Q <br /> 3 <br /> 00 �b�5 <br /> D <br /> k 1 VIT <br /> Id A y 0 <br /> SII a E' <br /> 59 X � Plp L��F, R J A UI C U <br /> h, N <br /> InkWWOME <br /> d6 <br /> n—_ <br /> DEPARTMENT'US O'LY <br /> Application Accepted By Date l0 tr U t-. Area ��� Employee ID# Sc�I �09 <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> r <br /> Character of Soil to Depth of 3 Ft: PitlSump Soil Character: <br /> COMMENTS %UO �a+�rG� �•�>rc�J �r7S O� �E� fT <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B as Remitted Service Request# _ <br /> 42-02-001 ONSITE WASTEWATER PERMF/ <br /> M 12/22/2003 <br />