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ONSITE WASTEWATIE 'REATMENT SYSTEM PERMIT Z,:?3p <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 'may/ 304 E WEBER AVE-3M0 FL-STOCKTON CA 95209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS -�rE�X�PIRE�(S IIYYEAR <br /> 1 FROM DATE ISSUED <br /> JOB ADDRESS 191 OA-V CITY/ZIP <br /> CROSS STREET0 APNVI 0o O PARCEL SIZE <br /> ETWyl_ C' � A NTt PHONEOWNER NAME k` � <br /> aADDRESS 0 7 ,o CT /STATE/ZIP <br /> CONTRACTOR VO <br /> PHONE <br /> CONTRACTOR ADDRESS G A CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y O <br /> PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION#T*-O2 00 17�p <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION L <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 0 <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE— TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R p <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE fl <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION I1 PROPERTY LME R <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> O <br /> ❑ SUMPS WIDTH fl LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION II PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft Z <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft 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 INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLEGZ,�S._ — DATE Al- O <br /> eweu <br /> Tj <br /> D <br /> 4�I DEPARTMENT USE ONLY tp <br /> Application Accepted By Date Oe Area Employee ID# S34b /C f <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B Cash emitted Date Service R uest# Invoice# Permit IDN <br /> 42-2---> 52-S ';k_�'600 . * od S 0 o3 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />