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►. '`/ <br /> I <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WESER AVE-3r°FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR 1\SPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOS ADDRESS 7'- �(�'✓ / CITV/ZIP Ar-e.1_VZ, <br /> r CROSS STREET 1 J S�I I-� �1� APN l_.(i`—rC� -/I PARCEL SIZE.� o <br /> OWNER NAME L�I7 '��YYIS C " z1G PHONE 7F <br /> OWNER ADDRESS ^ �1 /��Ill a CITY/STATE/ZIP / <br /> ` CONTRACTOR !1�l /�T PHONE ) <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R 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 /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL fl 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 R <br /> y 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 R DEPTH It —1^ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH ft +� <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE ft h <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <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"R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 12091953-7697 <br /> SIGNED ` P E /�-t_ DATE '•C LZ C' Y./ <br /> CIAVIVIENT <br /> 2G <br /> r. IUAUL IPI <br /> r� <br /> E <br /> DEPARTMENT SE \' k�qqq <br /> Application Accepted B _ Date Area Employee IDN `_? { <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by r <br /> ` Character of Soil to Depth of 3 Ft: Plt/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date PermiU Invoice# Permit IDN <br /> Code INFO B Cash Remitted Service Request# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 1222/2003 <br />