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ONSITE WAST VATER TREATMENT SYSTi PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL I IFAI,TH DOW11'MF.NT 304 E WFIIF;R AV lo-el""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT <br /> rr '/ CAU,(209)953-71597 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> OW <br /> JOB ADDRESS G 1�hn CITY/ZIP <br /> CROSS STREET n APN \J T1" — PARCEL SIZE 0 t w <br /> OWNER NAME I✓ C. )(P^-HO(�NE <br /> OWNER ADDRESS 2_ P u CITY/STATE/ZIP ✓ `�� <br /> W <br /> CONTRACTOR PHONE m <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y �l <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDLIENGINEER DESIGNED/ALTERNATIVE ( — <br /> ❑ ON REPLACEMENT DESTRUCTION v, <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: C <br /> l0 <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS V <br /> S <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL Il FOUNDATION Il PROPER"rY LINE fl <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 11 FOUNDATION fl PROPERI"LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DE ft <br /> DISTANCE TO NFAREST WELL ft FOUNDATION 11 PROP• I 'I F ft <br /> ElMOUNDED WIDTH it LENGTH 11 D• fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 11 PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH III (� <br /> T <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL fl FOUNDATION f1 PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> 1 HEREBY C Y THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HDR VANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE:CALL(209)953-7697 n (� <br /> SIGNED 7 TITLE DATE <br /> J <br /> I <br /> E <br /> E I E <br /> 1 <br /> I IQ11IrH All zs_# <br /> DEPARTMENT USE/ONL ' (( ENVIRONMENTAL HEALTH DIVI ION <br /> Application Accepted Date '�V Area �1 Employee ID# <br /> c-, <br /> Final Inspection Date C3 SPECIAL PERMIT-Approved by <br /> Character of Soil o D th of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/-_ Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Rec uest# Invoice# Permit IDH <br /> Zz b l 00 3 S <br /> 42-01-001 �i� ONSITE WASTEWATER PERMIT <br /> 12/2/02 <br />