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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3-FI.-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT 1 CALL. 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM`DATE ISSUED <br /> JOBADDRESS r :.J t�)"�''�� 1`J W 1 t1 �1 "{Z- I, (�. CITY/ZIP AL 41 1 'J L_ { <br /> CROSS STREET . C'fG Gj1.• -�- tet:'_ .. APN ✓�?.f 1 O "� C <br /> LC <br /> ` 7 I L J / PARCEL SIZE 2 <br /> OWNER NAME i;'{ ., 4 f..{{ r_•^1, PHONE C...2•!� <br /> OW'NERADDRE.SS 1 I j <br /> CITY/STATE/ZIP <br /> CONTRA, 'OR PHONE l �.n) ?'t-••. w` <br /> CONTRA(TOR ADDRESS ../ i 1. ',.,..:1..... {-�. ^__�_. •�,,.^.] CMIS[ATFPLIP ... C_,. zi �1 <br /> t P` <br /> 1..ICENSE ❑C42 ❑C-36 OTHER NUMBER _ EXPIRATION,DATE 5 <br /> YY 4TER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates - X Y <br /> ' PERC TEST # ''�,.✓';__ iF,,.DING PFR6HT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION 13 ENGINEERDF-CIGNED/ALTERNATIVE. <br /> REPLACEMENTZI DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE(MFO CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE.TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS ((,� <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL it FOUNDATION fl PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SvsiM) y <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS __ #OF LINES LENGTH OF LINES ft <br /> DISrANC'E1'0NEARESr WELL 11 FOUNDAHON ft PROPERTY LINE <br /> ❑ FILTER RED WIDTH ft LENGTH a DEPTH ft <br /> DISTANCETONF.AREST WELL- ft FOUNDATION It PROPERTY LINE fI <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH Il P <br /> DISTANCETONEARES-T WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH 11 DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH it DEPTH fl ' <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS "It MBER WIDTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION It PROPERTY LINE ft .w <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 /> MINIMUM i24 HOUR ADVANCE N0FICE REQUIRED FOR INSPECTIONS-PLF.ISE CALL(209)953-7697 1 �-Y <br /> ` <br /> SIGNED �'-t _ ''{ 1-----"' TITLE —�- DATE �<�<'Z <br /> j <br /> I _ 1 <br /> 1 <br /> I <br /> t <br /> 1 <br /> L <br /> P <br /> Iti <br /> ) <br /> � �--• aur <br /> E T <br /> ,I <br /> DEPARTMENT USE ONLY <br /> .Application Accepted By t fJ t/ ( �f�,-,� Datej Area Employee iD# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character, <br /> COMMENTS ;t <br /> PE SC Received ChecldfJ Amount Permit) <br /> Code INFO BY Cash Remitted Date Service Request# Invoice q Permit ID# <br /> 42-02.001 ONSITE WASTEWATER PERMIT <br /> 12!222003 <br />