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.r <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERAMNIV <br /> �" <br /> SAN JOAQUIN COUNTY ENV]RONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3—FL-STOCKTON CA 95202- 9)468-3420 <br /> NON-REFUNDABLE IIP11ERMIT � CALL(209)953-7697 FOR INSPECTIONS -�\E,,XPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS '�`T S to I I V 1�5 CITV/ZIP 1 110Y-r 1'J� <br /> m <br /> 051 <br /> CROSS STREET .APN 001_Cj;t}7PARCEL SIZE c <br /> `, A <br /> OWER NAME rl 11/t Y ) PHONE <br /> OWNER ADDRESS CITYISTATE/ZIP <br /> CONTRA 11 ne Zf��3 <br /> �•- 3 7 o I •`� <br /> CONTRACTOR ADDRESS 1 a.- CITYISTATE/ZIP I I <br /> LICENSE 7 C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: tt GEOCRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # "�J I3WLDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUM BER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLO\'EES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION R PROPERTY LME fl <br /> ❑ LIFT STATION SIZE TYPE OP PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> O <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE R <br /> ❑ FILTER BED WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE fl <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH It <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUmseR wmrR R DEPTH R <br /> DISTANCE TO NEAREST WELL It FOUNDATION R PROPERTY LINE ft <br /> 1 HEREBY CERTIFY"FHAT 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 /> N1 NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNE <br /> TITLE//InUIJ DATE� OJ <br /> TT-FT,6--r60g <br /> IDT-. <br /> Tt <br /> h r <br /> f� <br /> r - <br /> i c Urfa <br /> I INVR N EN FAL <br /> Ll ENT <br /> V <br /> DEPARTMENT USE ONLY <br /> Application A .Ry D. '�`•� Area Employee ID# 4� <br /> Final Inspec4 B _ m��'�� Date [I SPECIAL PERMIT-Approved by <br /> Character of Soil to Dep h of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check# it- <br /> Amount Date Permxl Invoice# Permit ID# <br /> Code INFO B, ash Remitted Service Re nest# <br /> "3 <br /> ONSITE WASTEWATER PERMIT <br /> 42-02-001 <br /> 12!22/2003 <br />