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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 / CALL 209 953-7697 FOR INSPECTIONS EXPII�-RES 1 YEAR <br /> FROM DATE ISSUED <br /> JOB ADDRESS �/ ��1 /l/t/ CITY/ZIPA- <br /> rn <br /> CROSS STREET /"��t/��lr/' J� APN ID 3/10 2 7? PARCEL SIZE D. v <br /> r � �p <br /> OWNER NAME �f `��.�r 1.1/l.� �' PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR <' PHONE <br /> CONTRACTOR ADDRESS Z � -/` CITY/STATE/ZIP - <br /> LICENSE -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 ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Zi NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 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) IN, <br /> LEACH LINES ❑ LEACHING CHAMBERS #of LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL {j U -rE 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 <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft N) <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 `jam <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> SEEPAGE PITS NUMBER / WIDTH r ft DEPTH ''7. > ft T` <br /> DISTANCE TO NEAREST WELL,�i�j .G' ft FOUNDATION �/'�� ��!' ft PROPERTY LINE <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 UR AD ' NCE:NOTICE REQUIRED FOR INSPECTIONS—PLEASE:CALL(209)953-7697 <br /> SIGNED +/;< �t�. TITLE 1�/f DATE �. <br /> w <br /> J <br /> J -f <br /> 1 <br /> W " y <br /> � 1 <br /> r <br /> DEPARTMENT USE ONLY OCT <br /> Application Accepted Bye Date fj Area tN C�*ee ID# J`y <br /> 9 .r-o. ggpp <br /> Final Inspection By ,.�.�.�.� Date �Q/.2 /6�, ❑ SPECTved by <br /> Character of Soil to Depth of 3 Ft: Prt/Sump Soil Character AITH pEPRRTNI <br /> COMMENTS /.�a �gz�p�/1ii 1i x 3l ^ c� 1.1N�L /0C�,� ip �� Ae4e <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />