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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)46g-3420 <br /> NON-REFUNDABLEPERMIT <br /> �+ CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> I %'1172- — c-, -vim_ - CITY/Zip S� <br /> + JOB ADDRESS <br /> CROSS STREET O --O APN 1 1 i 1 Q 'l -1 PARCELSIZE I D <br /> f. <br /> OWNERNAME Dt•R PHONE al <br /> OWNERADDRESS S�-..-� CITY/STAT'EIZ1P <br /> CONTRACTOR PHONE 7 <br /> CONTRACTOR ADDRESS CITY/STATE2IP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICALINFORMATION: Coordinates X Y <br /> PERC TEST. # BUILDING PERMIT# LAND USE APPLICATION# VVV,1 <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ ' REPLACEMENT I ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFGCAPACITY gal #OF COMPARTMENTS <br /> ❑ -GREASETRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) f(� <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft l <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ) <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft p <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCF.TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH _ ft LENGTH ft DEPTH ft -r <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH ft (` <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft <br /> DISTANCE TO NEAREST WF.LI. ft FOUNDATION R PROPERTY LME R <br /> 1 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-P1L�EASE CALL(209)953-7697 <br /> SIGNED TITLE f kA=,tom' DATE AN, \ <br /> fI <br /> i <br /> P <br /> IECJ <br /> O Q IN CC UMN <br /> T <br /> DEPARTMENT U E ONLY T Z <br /> I Application Accepted By Date- s(o� Area Employee ID# '73-7 <br /> Final Inspection By - Date// 13SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS41j.3 si _ a7,-7 1n _ z lm/ i aCA. I <br /> PE SC Received C Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By. Cash Remitted Service R uest# <br /> I <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12122/2003 <br />