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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 + i CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATEISSUED <br /> JOB ADDRESS CITY/ZIP L <br /> / /7 <br /> CROSS STREET I APN �` L�5- —C./Jy <br /> y � PARCEL SIZE <br /> OWNER NAME _! Q �L �CIP7� .; v <br /> PHONE � <br /> OWNER ADDRESS CITVISTATE/ZIP S_1C0e 'f6L/ <br /> CONTRACTOR L(� �i PHONE <br /> CONTRACTOR ADDRESS B CITY/STATE/ZIP <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 ❑ REPAIR/ADDITION 13 ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ - REPLACEMENT DESTRUCTION C <br /> INSTALLATION WILL SERVE: II ❑ 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 CAPArr gaEXfRnTF1NjED7: <br /> D PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUN id�TlIVI <br /> ft ft <br /> .I <br /> ❑ LIFT STATION SIZE TYPE OF PUMP _ PPrrHit M59 Q]L� .SEPARA7,AI$1fF�VCflIASEDfVSTEM) N <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #Mffx beiing11(fll 101rmJllt�C�Lt111nCr(JIn►IISII�LI�II�J}UeL� ft 1� !f <br /> DISTANCE TO NEAREST WELL ft FOUNDATI j 1viron <br /> �itt'IL�It�l�iS�Qp a r <br /> Ll FILTER BED WIDTH ' ft LENGTH j ft DEPTH f�f ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE �ft <br /> ❑ SUMPS WIDTH ft LENGTH - ft DEPTH ft I <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft: DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> E TC�FRTITHA <br /> o ft H I <br /> E ARE L ft UNDATION ft P ER LINE <br /> 1 <br /> I H EBAV R E HI PPLICON AND TH ORK WILL O IN ORDANCE TH N JO IN UNTV <br /> R NA S,5 TE AWS A RULESAND FSA A 1N COUNTY24 VA�N,C�E NOTICE REQUIRED FOR INSPECTIONS—PEASE CALL(209)953-7697 <br /> SIGNED TITLE C� GGl7��i DATE <br /> } .-i <br /> + <br /> A.�7 I I r — I u a. a - ' t L l Y _,_j i _ r l <br /> ~ r <br /> T rj <br /> I s <br /> T. <br /> Ply k_ Ej SIT <br /> : 1FE <br /> 5 <br /> 2. <br /> LI EE&IT c _ <br /> IVT <br /> i <br /> DEPARTMENT US ON 4 <br /> Application Accepted By l Area x1 Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by" / I <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> A <br /> I <br /> PE SC Received Check#41 !Remitted <br /> ount Date Permit/ Invoice# Permit lD# <br /> Code INFO B s Service Re uest# <br /> o <br /> 20&0LH0d0 ` <br /> f <br /> 42-02-001 ONSITE WASTEWATER PERMIT I <br /> 12/2212003 4 <br /> r <br />