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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 CALL 209 953-7697 r )R I\3PECTIO%S EVIRE§1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �Kw CITY/ZIP <br /> CROSS STREET L APN 4 D, PARCEL SIZE <br /> A al <br /> OWNER NAME PHOYE ) p�'�� <br /> OwNERADDRESS /J CITY/STATE/ZIP / <br /> Z;A/br' ✓ <br /> CONTRACTOR is2 /✓G PHONE O. <br /> CONTRACTOR ADDRESS CTTWSTATE/ZIP ` <br /> LICENSE 42 L3 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# 1 <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCj Ll COMMERCIAL HER <br /> NUMBER OF LIVING UNITS: //� !/ NUMBER OF BEDROOMS: 1�' NUMBER OF EMPLOYEES: <br /> id SEPTIC TANK TYPFJMFGL/-&IKS9414D— rJ�l/ � CAPACITY 12-040 gal #OFCOMPARTMENTS f <br /> ❑ GREASE TRAP TYPE/MFG h CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL G/ - ft FOUNDATION ft PROPERTY LINE �= R <br /> ❑ LIFT STATION SIZE TYPE OF P/UMP y�- L3 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ,LEACHING CHAMBERS !r��I��G//���ifn// S #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL�ft FOUNDATION w R PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER _WIDTH ... ft DEPTH —_ft <br /> DISTANCE TO NEAREST WELL—/-=ft FOUNDATION ft PROPERTY LINE R <br /> I HEREBY CERTIFY THAT 1 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 /> a 1 MUM 24 OUR ADVANCE 'I :REQUIRED FOR INSPF.CT(ONS-PLEASE.CAU.(209)953-7697 <br /> SIGNED J'00,T I TL Eb49iv- - DATE <br /> LI+;-. <br /> Izi w <br /> L <br /> I <br /> P N <br /> H <br /> DEMJJPARTMENT USE ONLY /qQ <br /> Application Accepted Date Area Employee ID#�7 3(0� / <br /> Final Inspection B Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dep of 3 Ft: Pit/Sump Sod Character: <br /> COMMENTS Ajj2 ty2tj fitiall p <br /> PE SC Received Cha Amount Permit/ <br /> Code INFO B ash Remitted Date Service Request# Invoice# Permit IDN <br /> HZI( 1I5O. D 5 Z <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12222003 <br />