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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)468-3420 <br /> NON-REFUNDABLE PERMIT 1 �CALL 209 9$3-7697 FOR INSPECTIONS , EXPIRES I YEAR FRO/M�DATE ISSUED <br /> JOB ADDRESS 0 1'� i�R^� _ CITYfZIP l/V 1•"'l -l Z iiP <br /> Tl ` <br /> CROSS STREET s APN _O O 1— PARCEL SIZE <br /> ►/ 1 p <br /> MEn1C'(N i y <br /> OWNER NAME PHONE <br /> OWNER ADDRESS CITYISTATFJZ1P_ - 1 <br /> CONt'RACTOa _ _-_ PHONE - <br /> i <br /> CONTRACTORADDRESS gCrTV/SPATE/ZIP riZ <br /> I <br /> LICENSE. ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST #---I, I BUILDING PERMIT# __ _ LAND USE APPLICATION#�14� �C17ad"Z <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAHUADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT 13DESTRUCI'IOn , <br /> INSTALLATION WILL SERVE: O RESIDENCE ❑ COMMERCIAL ❑ OTHER G <br /> NUMBER OFLIVING UNITS:_ _ _ NLMBEROF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG. CAPACITY gel #OF COMPARTMENTS 4+ <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY _ gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION—__ ___ R PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYST.64) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES_ A�fl <br /> DISTANCE TON£AREST WELL R FOUNDATION_ .__ R PROPERTY LINE <br /> ❑ FILTER BED WIDTH ft LF.NGTII _ ft DEPTH <br /> DISTANCE TO NEAREST WELL______ R FOUNDATION R PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH _ - _R DEPTH ft <br /> DISTANCE TO NEAREST WELL _--R FOUNDATION R PROPERTY LINE fl <br /> ❑ SUMPS WIDTH ft LENGTH — - ____�fl DEPTH fl <br /> t <br /> DISTANCE TO NEAREST WELL, ft FOUNDATION 11 PROPERTY LINE 0 <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WDTH fl DEPTTI ft <br /> DISTANCE TO NEAREST WELL-_ R FOUNDATION R PROPERTY LINE R <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK W'11.1.BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 N <br /> SIGNED TITLE F+.s.� DATE �� G <br /> r <br /> 4A h <br /> ±H4 <br /> U <br /> 4 <br /> "- DEPARTMENT SE LY <br /> Application Accepted B Date Arca Employee ITkI J <br /> Find Inspection By _� Date Q SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept 1`3 Fl: PIUSump Soil Character: <br /> COMMENTS <br /> PE SC Received CheclL# Amount Date Permld Invoice# Permit ID# <br /> Code INFO By ash .Remitted Service Re uest# <br /> z,-22. 5.2 l O S. 2p SS <br /> 12-02-001 ONSITE.WASTEWATER PERMIT <br /> 12122/2003 <br />