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ONSITE WASTEWATER TREATMENT SYSTEM PERMI IpS'O/�/�f <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRE I YEAR FROM DATE ISSUED <br /> JOB ADDRESS / CITY/ZIP <br /> CROSSSTREET APN cQ,0.7 _ / PARCE SIZE 0'TC— D <br /> OWNER NAME (--1 C7�„��L` <br /> /�-•��/ PHONE <br /> OWNERADDRESS :7 CITY/STATEIZIP ZZ)A G 110/�C(�r-D vQ�>�o��2 S-T y <br /> \ <br /> CONTRACTOR c/ N PHONE <br /> L.In Z4 <br /> CONTRACTOR ADDRESS _ CITY/STATE/ZIP <br /> V <br /> LICENSE, C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE za <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TESTN BUILDING PERMIT# AND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAtR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG Nl-�J Ae'/� //ADD <br /> CAPACITY gel NOF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG /'7 CAPACITY gal NOF COMPARTMENTS_�Ww <br /> - ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL / V R FOUNDATION �D ft PROPERTY LINE 7—oo ft <br /> ❑ LIFT STATION SIzE TYPE OF PUMPr ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) f\R_ <br /> ,BLEACH LINES A—LEACHING CHAMBERS �3 N of LINES_-;� LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL /S'D It FOUNDATION 5-0 ft PROPERTY LME R <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE To NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH it LENGTH ft DEPTH fl <br /> DISTANCETO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> SEEPAGE PITS NUMBER�_WmTll _R DEPTH �. R <br /> DISTANCE TO NEAREST WELL R FOUNDATION �� ft PROPERTY LINE ;�2,a Q R <br /> 1 HEREBY CERTIFY THAT I 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 /> IMUM 24 HOUR ADVANCE NO"ICE REQUIRED FOR INS <br /> PECTI0 LE SE CALL(209)953-7697 <br /> SIGNED L'_ X= DATE fQ <br /> Z <br /> Y <br /> I <br /> 3 X <br /> ,. <br /> DEPARTMENTSE O'LV $3�k q g y <br /> Application Accepted By f/L — Date , R O-`: Area Employee IDN <br /> Final Inspection By Date ' ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS �UtFw c-1 C) le€Co.Q� MS-�l7-U'F V v Mw <br /> , <br /> PE SC ReceivedgfieckN Amount Permit/ Invoice N Permit ID# <br /> Code INeo B s Remitted ata Service Request# <br /> 3—s <br /> 42-024)01 ONSITE WASTEWATER PERMIT <br /> 1282/2003 <br />