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a— <br /> am <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-39°FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> a. <br /> JOB ADDRESS 7 1 �' - L i-T) L y ( N CITY/ZIP <br /> CROSS STREET ( 4 11-A f IJ S 1- APIN `��� PARCEL SIZE <br /> OWNER NAME I f A (: f e� F.'.f I P 4+� PHONE— '3 <br /> OWNER ADDRESS I Y- / "`� CITY/STATE/ZIP I 1 c n5"f A' 1 �' 7 <br /> ta_ ' <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS - - CITY/STATE/ZIP I <br /> ( <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X V <br /> EI PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> tam <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL It FOUNDATION ft PROPERTY LME 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 R FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH 11 <br /> DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE ft <br /> _ ❑ MOUNDED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME it <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH (1 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER Wmrx ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> I 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIO-'S-PLEASE CALL`—(209)993-7697 <br /> SIGNED I •`�" ` ,-^-1 TITLE ! • c DATE_��i i=}-�J- t <br /> bin <br /> 11 I <br /> i I I <br /> rA. I A F NI T <br /> 'I I <br /> 1 7 <br /> bw n <br /> C <br /> iiH EESM ME NT <br /> I <br /> rata <br /> 1 DEPARTMENT JUSE O LtrY <br /> Application Accepted By. ..r\, (- 41`<\.� Data I T Area Employee ID# <br /> No <br /> Pinel Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Sell to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> aass, <br /> PE SC Received - ChecW1 - Amount Perm1U <br /> Code INFO B /Cash Remitted Date Service Request# Invoice# Permit ID# <br /> Z <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />