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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 1 YE R FROM DATE ISSUED <br /> JOB ADDRESS ( �: Si-�u-e. CITY/ZIP <br /> CROSS STREET j k\ Ic i-k APN ®� (3 /V 11 PARCEL SIZE <br /> OWNER NAMELet ( PHONE <br /> J <br /> OWNER ADDRESS CITY/STATE/ZIP +`� <br /> CONTRACTOR a S <br /> PHONE �tf 3 z���� <br /> CONTRACTOR ADDRESS ?\a Il i'L)Sty-) ( {�GCIT/Y�/'$STA/TE/ZIP�c 4? <br /> LICENSE 42 ❑C-36 OTHER NUMBER EXPIRATION DATE C� L <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: ,Y <br /> ❑ SEPTIC TANK TYPE/MFG 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 /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 <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 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 /> I 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 /> MINIMUM 24 VANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> SIGNEDN U . TITLE C'(OCNI DATE L <br /> tAffl <br /> L <br /> FIV _-Ul Fir <br /> NI AA <br /> AN JOAQUIN OU T <br /> 11 PUB 77 FA7 TM. <br /> UD i',LOLL. <br /> DEPARTMENT U E ONL <br /> Application Accepted B Date a- Area Employee ID# (j <br /> Final Inspection By Date \-3 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS Ya )', �a ,D <br /> e A2 I d D YG� 07? <br /> PE SC Received Check#/ ' Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B -�asfi Remitted Service Request# <br /> l ? '33 a3 S�DO D P <br /> 42-01-001 <br /> 12/2/02 ONSITE WASTEWATER PERMIT <br />