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- <br /> N� 11 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <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 INSPE(*TIONS EXPIRES II YEAR FROM DATE ISSUED <br /> JOB ADDRESS )o CITY'/ZIP <br /> r / �'Q th <br /> CROSS STREET / PI I�L f'7,L.L APN � �O O PARCEL SIZE �,�Z D <br /> O <br /> /^ O <br /> OWNER NAME ,/t,'��(�' /N%/V ^ PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS (, 6� CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER A NUMBER - EXPIRATION DATE <br /> WATER TABLE.DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE.OF WORK: 0 NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ® RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: J NUMBER OF BEDROOMS: / NUMBER OF EMPLOYEES: <br /> ® SEPTIC TANK TYPL/MFG L 1�L L `�/`�(�'tet 1 CAPACITY L) gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS�S <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL /G�d tl FOUNDATION ft PROPERTY LINE G? ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) Q <br /> ❑ LEACH LINES ® LEACHING CHAMBERS FC..) Z #OF LINES_� LENG'IH OF LINES l' J ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION tl PROPERTY LINE it <br /> ❑ FILTER BED WIDTH ft LENGTH fl DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ N10UNDED WIDTH ft LENGTH ft DEPTH fl <br /> DISTANCE TO NEAREST WELL Il FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTII Il LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WI L1. ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ti LENGTH ft DEPTH ft <br /> DISTANCE.TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE ft <br /> 12 SEEPAGE PITS NUMBER -3 WIDTH 3 .7 R DEPTH Z S fl <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROF&7YLINE <br /> I HEREBY CERTIFY' HAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCF.WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGLLATIONS OF SAN JOAQUIN COUNTY. <br /> ti <br /> 11%INI ,24 HYUR AD%ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 1'_09)951-7097 l <br /> SIGNED TITLE 2,\ fi/ tv� DATE. / O S <br /> fj <br /> 2 <br /> P <br /> zf <br /> c u <br /> _13' <br /> �� I ' <br /> TN F <br /> IR t4 N <br /> LN <br /> v , <br /> Li <br /> DEPARTMENT U'E ONLY <br /> Application Accepted By \ Date Area Employee ID# ,I <br /> Final Inspection B Date- / ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth/of 3 fit: J , Pit/Sump Soil Character: <br /> COMMENTS <br /> Jq /'f�ltS i«'. /J C-A,16 7-1- r/'/%� % 7 7,�, <br /> PE SC Received ec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By ash Remitted Service Request# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> -2:'2003 <br />