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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> I I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"D FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 2099 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS C} T ✓J CITY/ZIP <br /> zz /J� � <br /> CROSS STREET APN �0✓ 07 PARCELSIZE 0- <br /> v <br /> OWNER NAME I /4/. -LD/J PHONE y <br /> OWNER ADDRESS / CITY/STATE/ZIP <br /> , \, <br /> CONTRACTOR 1c �- '� -C1Ci� PHONE � �- ��3 Dj <br /> r <br /> CONTRACTOR ADDRESS `/c:3 L' 'C CITY/STATE/ZIP D <br /> W <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER T EXPIRATION DATE / I Z X-�2411197 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: 0 NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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 TYPE/MFG CAPACITY / 2y gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS C <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL �G 9 Gj ft FOUNDATION S ft PROPERTY LINE �© ft <br /> 1 <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 0 LEACH LINES ❑ LEACHING CHAMBERS #OF LINES L LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION `2 a- ` ft PROPERTY LINE r V 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 <br /> DISTANCE TO NEAREST WELL ft FOUNDATI i ft PROPERTY LINE ft <br /> An SUMPS WIDTH ft LENGTH / ft DEPTH /� ft <br /> J�� 5 <br /> DISTANCE TO NEAREST WELL ''2-1:'` ft FOUNDATION /4t�O ft PROPERTY LINE /O' ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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. I Z 1 <br /> IMUM 241 ADVANCE:NOTICE REQUIRED PORI SPEC/TI�ONS-PLEASE CALL(209)953 97 � _ <br /> SIGNED TITLE C,c�f lr / 1� ATE �p <br /> — r <br /> i <br /> f J I <br /> C, <br /> E Vli"i.}i'EV1[-NTAL <br /> EA 11 0_HA0 E. <br /> DEPAR N SE <br /> C !% <br /> Application Accepted By Date S Area Employee ID# <br /> Final Inspection ByDate ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depd of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS CX p L6T bl= (XbCo FA 2 <br /> PE SC Received eck# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By ash Remitted Service Request# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />