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ONSITE WASTEWATF TREATMENT SYSTEM PERMIT <br /> ` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3P°FL-STOCKTON CA 9526../(209)468-3420 <br /> NON-REFUNDABLE PERMIT t CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> p 0 �yyyttt �t -i <br /> CROSS STREET N t I Y Rrm APN�,'( I" � PARCEL SIZE -15 I o <br /> OWNER NAME C"7l. a V1 do T—�� uA�i <br /> 7 PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP y <br /> CONTRACTOR PHONE �)) <br /> CONTRACTOR ADDRESSJAIIA WIM IN . rl Vl <br /> ,.LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# I� — <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 /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> i ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION R 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 /> r <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH el ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ' <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <br /> a� DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH R - <br /> DISTANCE TO NEAREST WELL ft FOUNDATION _ ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> rnl DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R - <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> r ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. / <br /> (/./1MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPEC IONS/-PLEASE CALL(209)953-7697 <br /> SIGNED `��C.CIK � TITLE -)/ 'f� DATE <br /> I <br /> 111C L <br /> E ' ` <br /> It <br /> 1 � <br /> N 116' <br /> -5 <br /> t - El,VI Oh M <br /> i I <br /> DEPARTMENT U E O LY <br /> Application Accepted By_ .T�^-. Date 0 �S Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of Ft: '\ Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By as Remitted Service Request# <br /> 42.21- 5-2- ? 173 n2.00 lb c c foo 14u SS c' <br /> rr 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/222003 <br />