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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 <br /> �P jER)MIT CALL(209)943-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> 108 ADDRESS `�1 r2 *-1-'� 1'-Y 1J CITY/ZIP G(L to� - <br /> C� 11 aS� =1 <br /> CROSS STREET 'S`�-� �� _ APN f ! `� - PARCEL SIZE <br /> OWNER NAME la n j-o 3-,ng <, PHONE <br /> OWNER ADDRESS I J- 5tvc k_h Jrn CITYISTATE/ZIP ✓ <br /> r'! <br /> CONTRACTOR PHONE O� <br /> CONTRACTOR ADDRESS C ITYISTATEIZI P <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE ht <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# r� <br /> TYPE OF WORK: ❑ NEW INSTALLATION Cl REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE l <br /> ❑ REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER JN <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 C1 <br /> r-jkjuJINGABAM hNT# rel`" <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <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 tt DEPTH tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> SIGNED L t r zt'a-i' `' .��fiK.>�� TITLE DATE <br /> E MEN <br /> i.j -�C101Q ,0 lqcaulfll <br /> q4 LjEl'ARTM 'NT, <br /> 01� 11k PEE <br /> is r <br /> i'rii' p1V"f" I- ' <br /> DEPARTMENT USE 01V1:Y-" <br /> Application Accepted By L( I/l A Date Area Employee ID# <br /> Final Inspection By Date 14 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: 0 Alsifinp Soil Character: <br /> COMMENTS <br /> PE SC Received heck# Amount ate Permit/ Invoice# Permit ID# <br /> Code INFO ash Remitted cc a uest <br /> 15 i <br /> 42-01-001 <br /> 12/2/02 ONSITE WASTEWATER PERMIT <br />