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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"FL-STOCKTON CA 95202 -(209)469-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSP CTIONS ��E`XPIRES 1/YEAR FROM DATE ISSUED <br /> JOB ADDRESS 47 3 C! ♦ T -`C CITY/ZIP / ,.1J (4 (J <br /> CROSS STREET >t APN J D L7�' PARCEL SIZE G 4�, o <br /> J '�J y A <br /> OWNER NAME � C�C� I CJ G Y\ In; PHONE �i' !_J <br /> OWNER ADDRESS '2 C �Cl 4A r'f \CSI CITY/STATFIZIPo <br /> CONTRACTOR O'^ �%�' I - 1 I U • PHONE <br /> CONTRACTOR ADDRESS CRY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER - EXPIRATION DATE n <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # 1 BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE El COMMERCIAL L) Orxea <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: r NUMBER OF EMPLOYEES: <br /> LJSEPTIC TANK TYPE/MFG <br /> n <br /> T N 1. C"C.I'— '�C_ CAPACITY �tr�C� gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL rte.- it FOUNDATION it PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ` ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINESyEACHING CHAMBERS 0 Olt C1 Qi #OF LINES LENGTH OF LINES <br /> l��eUC� ft <br /> 9/DDIISTANCEToNEAREST WELL I SC V fl FOLNDATION it PROPERTY LINE ✓F "F fl V <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH fl LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LME R <br /> ❑ SUMPS WIDTH fl LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTN ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> I 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 /> MIND U 24 R ADV VCE OT REQUIRED FOR INSPECTIONS-P.EASE CA (Z09)953-7697 <br /> SIGNED e7-11 ��rj�^� TITLE C-�Ur��•t'v.-t�F_��i•� DATE <br /> E <br /> Lt <br /> i <br /> EPARTMENT USE NLY <br /> Application Accepted By _ Date Area Employee ID# 7`noo _2 <br /> Final Inspection By Date —2E—LOS ❑ SPECIAL PERMIT-Approved by �S •Jw�, <br /> Character of Soil to Depth of 3 t: / Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Choc Amount Date PermiU Invoice# PermitID# <br /> Code INFO By Cash Remitted Service Request# <br /> L SIRS ) o DO <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 1222.'2003 <br />