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Z.'v-D <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3""FL-STOCKTON CA 9$202 - (209)468-3420 <br /> NON-REFUNDA LE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR F5p DAT ISSUE <br /> JOB ADDRESS CITY/ZIP: M c <br /> CROSS STREET /6 APN PARCEL SIZE `J <br /> v <br /> Ora �7r Ing <br /> OWNER NAME s ' PHONE <br /> OWNER ADDRESS ^ CITY/STATE/ZIP <br /> ) 9 <br /> CONTRACTOR PAP-04 45 (4S.. � PHONE <br /> CONTRACTOR ADDRESSCITY/STATE/ZIP <br /> LICENSE C-42 ❑C-36 OTHERrn NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ' ❑ PERC TEST # —� BUILDING PERMIT# LAND USE APPLICATION# <br /> li TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> i ❑ 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 gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS -- <br /> f <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION C ft PROPERTY LINE 15 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES )( LEACHING CHAMBER 36 #OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 15 <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft rn <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 ftp <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. <br /> MI "IM V C OTICE REQUIRED FOR li 1 SNS- L f L(209)953-7697 i <br /> SIGNE /� TITL DATE V L6 �Ckn' <br /> Ike <br /> f <br /> AL 1 IV <br /> i <br /> r' DEPARTMENT U$E ONLY' <br /> - - (?-,r--7 <br /> Application Accepted By _ Date J rtrea---- - --Emplc\ <br /> Final Inspection By - Date �/j/�j 11 SPECIAL PERM ITN t \ I <br /> Character of Soil to Depth of 3 Ft: Pump Soil Character: ` <br /> COMMENTS : <br /> 1t t l1 6, C c./T i I 4--t i2 c4' C t. -�v.it7—r L_ �' 4•u i � r v Il.,Ii <br /> f <br /> PE SC Received ec Amount ate Permit/ Invoice Permit ID# <br /> Code INFO Cash Remitted PService Request# <br /> l� 512-Q <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />