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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 -(2119)468-3420 <br /> NDN-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTION- EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS S f V QTvIZIP 9"16 <br /> CROs STREET t $! wP <br /> F a`f�7o�Dn c4 PARCELSI7,EA� <br /> N <br /> OWNER NAME DzP 1M4 12 6, A Fe rm-1, _ PHONE <br /> rJWNER AODRE9S CITYISTATEMP <br /> CONTRACTOR y I G L QeL PHONF' & <br /> f <br /> CONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE ❑C42 ❑C-36 OTHERNUMBER ExPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INVORMATtON: Coordinates X V <br /> I ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: Cl NEW INSTALLATION REPAIR/ADDtr1oN U ENGINEER DESIGNED JALTERKATIvE <br /> ❑ REPLACEMENT ❑ DESTRucnoN <br /> INSTALLATION WILL SERV& RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING U?srrs: NUMBER OF REbROOMS: NDASRER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYFWMFG CAPACITY <br /> SAI pOF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFO CAPACITY gel #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCETO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> CI Li Pr STATION SIt1 TYPE OP PuMP O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> Q' LEACH LINES W LEACHING CHAMBERS !}� + <br /> Fi <br /> L #OF LINES� LENGTH OF LINES <br /> DinANCETO NEAREST WELL I CIA! R FOUNDATION �p r ft PROPERTY LME <br /> ❑ FILTERBED Wlcgn ft LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTn ft LENGTH R DEPTH R <br /> F! DISTANCE TO NEAREST WELL ft FOUNDATLON ft PROPERTY LINE R <br /> ❑ SUMP$ WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINO R <br /> F U DISPOSAL PONDS WMTN ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTYLINR R <br /> a SEEPAGE PITS NuMBeR WEM R DEPTH (t <br /> F <br /> TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNCY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQIJIK COUNTY. <br /> M NIMUM HOUR ADVANCF NOTICF REQUIRED FOR INSPECTIONS-PLEASE <br /> rCALL(209)953-7697 <br /> SIGNED TITLE_ Co SCC.r-V-G r DATE �n <br /> r D <br /> 1 <br /> h <br /> F4 <br /> iI <br /> E <br /> INA <br /> -A,r <br /> T <br /> N <br /> H <br /> DEPARTMENT USE A Y n <br /> J Application Accepted By Date s Area � Employee[D# <br /> Final Inspection By Date Q SPECIAL PERMIT•Approved by <br /> CharactererSolltolle 0Ft: PltlSumpS,01,"aracler: <br /> FCOMMENTSc;go & <br /> r <br /> f PE SC Received Ch AmOun[ Dak PermlU Invoice# Permit IDN <br /> Code INFO By Remitted Servke R cell# <br /> & FD— rr ),- D 03 L- <br /> j 42-02-M] ONSITE WASTEWATER PERMIT <br /> 12122!2003 <br />