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• ' ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE.3"FI.-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT P CAI 1,(209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE SSUED <br /> JOB ADDRESS ✓tl I l (/{/ deQ CITY/ZIP O v <br /> CROSS STREET �T> APN�-lgo K PARCEL SIZE L -OS- o <br /> OWNER NAME ��} -Tri/lVfil- �� <br /> PIIonE <br /> �_� / � ov J( <br /> OWNER ADDRESS 2 5tUI [.��N CITY/STATE/ZIP L <br /> CONTRACTOR C <br /> PHONE <br /> CONTRACTOR ADDRESS <br /> CITY/STATE/ZIP <br /> LICENSE C42 ❑C-36 OTHER <br /> NUMBER_� EXPIRATION DATE <br /> WATER TABLE DEPTH:__ ft GEOGRAPHICAL INFORMATION: Coordinates X y <br /> ❑ PERC TEST # BUILDING PERMIT# 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: <br /> �!'�� y, <br /> .SEPTIC TANK TYPE/MFG �N� CAPACITY ,'/7� / gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY`c _ gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LME R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑/S2AdD SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS /� /� #OF LI SES .1 3 LENGTH OF LINES � _R <br /> DISTANCE TO NEAREST WELL_�V V H FOUNDATION l U :! ft PROPERTY LINE [7 ( ' fl <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> C] MOUNDED WIDTN ft LENGTH R DEPTH it <br /> DISTANCE TO NEAREST WELL fl FOUNDATION R PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION III PROPERTY LINE H <br /> ❑ DISPOSAL PONDS WIDTH_ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE It <br /> I <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 /> MINIMUM 2 NUl'R/rUV�A/�C'F N0110E REQUIRED FOR INSPECTIONS-PI.F.ASE('A 1.1.1 91 951.7697 <br /> SIGNED TITLE � DATE <br /> 701 <br /> G7 <br /> IV <br /> Z_ <br /> y <br /> N Y <br /> A T DAf T <br /> t DEPARTMENT U'E ON <br /> .Application Accepted to Area Employee ID# <br /> Final Inspection By ■te ❑ SPECIAL PERMIT-Approved by <br /> Character of Soll to De hof 3 Ft: PIU, mp Soil Character: <br /> COMM NTS <br /> v� <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B emitted Service Request# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 1212212003 <br />