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SCANNED _. <br /> 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 INSPECTION'S EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /(/ 6 CITY/ZIP <br /> re <br /> CROSS STREETAPN f r� 5-J - CS PARCEL SIZE C d <br /> OWNER NAME oz,- PHONE 69 7Ot <br /> OWNER ADDRESS �n�� �GifZ_ CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS 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(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ 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 C CAPACITY I j�J gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY 1-7 <br /> gal #OF COMPARTMENTS <br /> Ll ]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) <br /> EACH LINES ❑ LEACHING CHAMBERS,��•T / (!�� #OF LINES _� LENGTH OF LINES V tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tt <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 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 TTo NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS WIDTH Jft LENGTH ft DEPTH RL- ft <br /> ✓ DISTANCE TO NEAREST WELL ' ft FOUNDATION fi 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 ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> NED f�M M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> .wj �.GG4 G 111 �� TITLE 0/i-i O� C'-yam DATE `" ~ <br /> a. <br /> I <br /> i <br /> ,7 <br /> ' 4 u <br /> tt` <br /> _ O1V <br /> i4 I-A--I- <br /> e I <br /> l N <br /> S Nc'�., ITI[1`1g1. <br /> DEPARTMEN IS ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS -k4fiV .5-150 <br /> � �,erntio <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted I Service Request# <br /> 42-01-001 <br /> 12/2/02 ONSITE WASTEWATER PERMIT <br />