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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 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> Joe ADDRESS 1 1, �-`157 't/y ' I ri w �+ o .,o CITY/ZIP <br /> CROSS STREET ( - APN PL `� 'T v O ( PARCEL SIZE t ✓ Ptro <br /> t {{ q f F <br /> OWNER NAME '^' � 1 1 O. PHONE <br /> OWNER ADDRESS CITYISTATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 14 PERC TEST #__It BUILDING PERMIT# LAND USE APPLICATION -v -74 <br /> > I <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> I <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: i <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> I <br /> ❑ GREASE TRAP . TYPE/MFG CAPACITY gal #OF COMPARTMENTS j <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION R PROPERTY LINE R <br /> i <br /> ❑ LIFT STATION SIZE TYPEOFPUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) I <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R = <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R V. <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft .� I <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH R LENGTH R DEPTH it <br /> DISTANCE TO NEAREST WELL - ft FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH - ft LENGTH ft DEPTH ft r. <br /> DISTANCETONEAREST WELL ft FOUNDATION- ft PROPERTY LINE ft - <br /> ___,❑ SEEPAGE PITS NUMBER WIDTH R DEPTH It r <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R L. <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 /> MINIMUM 24 HLl}1R ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 C <br /> 1 SIGNED - - TITLE �.>.r DATE <br /> d BURI4'W IARMn�`1�^'OtACi <br /> PIACEMIA 111_AVEHUE <br /> r�'.m•.,a.00 <br /> I PAR»da,�t• I ! PARCEL,., I f� <br /> I t l I \\4 <br /> TEMPLE g CREEK I <br /> 3gg� PSEsAtj <br /> '3' PACED"4" 4� <br /> H H E T <br /> 'EILVIODO ROAD ' <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �-- WYE Date f±��i Area Employee ID# <br /> Final Inspection By Date - ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/SumpSoil Character: <br /> COMMENTS <br /> PE SC Received Ghee Amount Dae - Permit .Invoice# Permit ID# <br /> Code INFO B Cash Remitted Seivl. . .est# 1 <br /> -2/ f ' 3.72 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />