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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 EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS MID AV CIITY/Z/I�P �j -I <br /> CROSS STREET ��"3J� C �T f� 1/1iC ''� /L LVID APN I �l �!_7l ,q� 5 Ft?, tPA�RC�ELSI,Z�'�E�4 -3LI' �O <br /> OWNER NAME /'�S�F�Jt�,� Ef J IG J � i' PHONE <br /> '�"/ICL36 - 1 32 <br /> OWNER ADDRESS CITY/STATE/ZIP (1C, �1�� 952 <br /> ^ <br /> �5 N <br /> CONTRACTOR ' te4C& N1 wl l ../ 1 <br /> PHONE-960-7 <br /> CONTRACTOR ADDRESS ' RMV CITY/STATE/ZIP <br /> l �E t l <br /> LICENSE C-42 El C-36 OTHER �IYUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: )K NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> i i <br /> NUMBER OF LIVING UNITS: i NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG L Cil' 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) <br /> 9 LEACH LINES ❑ LEACHING CHAMBT�R � #OF LINES 7' LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL _1 ft FOUNDATION—20 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 'i <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> / SUMPS WIDTH ft LENGTH /f't� r DEPTH ft <br /> DISTANCE TO NEAREST WELL _I 5 ft FOUNDATION � ( 1 ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT I 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 /> NIMIN 24 ,. VNCE NOTICE REQUIRED FOR 1. IONS-PL ASE CALL(209)953-7697 <br /> SIGNED ✓ � 1R �� TITLE �� DATE 15 16�04 <br /> SA `1 Q RV ''r. <br /> d O - — - - N ;rr L <br /> -C <br /> DEPARTMEN U 0 ' Y <br /> Application Accepted B - Date a � Area L/ Employee ID# 5YVv—,4Y <br /> Final Inspection By Date / y ❑ SPECIAL PERMIT-Appr ed <br /> Character of Soil to Depth of Ft: Pit/Sump Soil Character: <br /> COMMENTS ed s <br /> J <br /> PE SC Received C Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> 42-01-001 <br /> 12/2/02 ONSITE WASTEWATER PERMIT <br />