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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -YO FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL }209 953-7097 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS / �J�I CITYIZ[P f G <br /> .1 <br /> CROSS STREET (�.�Le �G.���F7- �f _ APN 0 5" z✓ / ,- PARCEL SIZE <br /> OWNER NAME1 CX/{ CYC �1 �If/' r� PHONE ff <br /> OWNER ADDRESS CITY/STATEIZIP <br /> G / i <br /> CONTRACTOR Ca'I� �D�� �� PHONE '7�F - Cs 7C�b <br /> CONTRACTOR ADDRESS G G7' CITVISTATEIZIP E- s2 <br /> LICENSE ❑C-42 ❑C-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: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNS /ALTERNATIVE <br /> LI REPLACEMENT DESTRUCTION C <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 <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) N <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 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft M ' <br /> ❑ 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 <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft P <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH it <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 /> INIMU 24 V�ANNC��E NOTICE REQUIRED FOR INSPECTIONS-P EASE CALL(209)953-7697 a� <br /> SIGNED TITLE t' G� f( DATE <br /> _ PA <br /> E <br /> flu <br /> EB <br /> I T17 All !AMC JUA u 4TY <br /> IV lRTA <br /> DEPARTMENT US ON a <br /> Application Accepted By to Area C'-I i Employee lD# > y 1 <br /> 2 <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by /w- <br /> Character <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check# Amount Date Permit! Invoice# Permit ID# <br /> Code INFO B as Remitted Service Request# <br /> 5 cr -f 10 3 a Ja3o_sb5 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />