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/"-3 0 <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3µD FL-STOCKTON CA 9520 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> 1�S I CITY/ZIP � 3 cy 1 +fin CA Q l b& : <br /> JOB ADDRESS <br /> t� <br /> CROSS STREET APN ! t'S ' / 27 PARCEL SIZE <br /> � i� <br /> OWNER NAME � <br /> �G PHONE n <br /> y <br /> OWNER ADDRESS EG� CITY/STATE/ZIP <br /> CONTRACTOR I R PHONE <br /> CITY/STATE/ZIP < ery' Y cj <br /> CONTRACTOR ADDRESS <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ ERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> P <br /> TYPE ER WORK: LI NEW INSTALLATION -7 LJREPAIR/ADDITIO ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT S �'Ll <br /> 5OF I DESTRUCTION U J) +� <br /> INSTALLATION WILL SERVE: 0,-TESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> 2"--SEPTIC <br /> ,NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF�EMPLOVEES: -�� <br /> 2 SEPTIC TANK TYPE/MFG '�L CAPACITY gal #OF COMPARTMENTk, <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL <br /> t- ft FOUNDATION—cam-- ft PROPERTY LINE�)S- 1 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 91-'LEACH LINES ❑ LEACHING CHAMBERS #of LINES LENGTH OF LINES i�ft <br /> DISTANCE TO NEAREST WELL CL1 ft FOUNDATION �) 1 ft PROPERTY LINE S j ft <br /> ❑ FILTER BED WIDTH ft LENGTH <br /> 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 <br /> 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 Fy? <br /> I ft <br /> gASEEPAGE PITS NUMBER t r^ WIDTH_q {. ft DEPTH 1 <br /> DISTANCE TO NEAREST WELL 1 56, <br /> c,,1 _ft FOUNDATION 4�_ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 1 HOAVE PREPARED THIS <br /> STATE AWS ANDAPPLICATION <br /> O <br /> RU ES AND REGULATIONS OF SAN ITH SSAN JOAQUIN COUNTY <br /> JOAQUIN COUNTYIN ACCORDANCE W <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE era4 � '� DATE <br /> I r <br /> .l <br /> 2� <br /> © .zE <br /> i <br /> DEPARTMENT UJEO ILV / <br /> Application Accepted B <br /> Date -2 e' Area Employee ID# •3 ! <br /> Final Inspection By. Date lJ ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to a of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS UC A L__c- ��F � cc% �24=0 <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> 05— 2.3o•C-LI Q !� <br /> ONSITE WASTEWATER PERMIT <br /> 42-02-001 <br /> 12/22/2003 <br />