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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT . <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3YD FL-STOCKTON CA 95202 - (209)4663420 <br /> j NON-REFUNDABLE/PERMIT CALL(209)953-7697 FOR INSPECTIONS' - EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 'y1 /� - - - - [/j CITY//ZIP <br /> CROSSSTREET' 1 , ,/�c AIR.l+,IA�. APN 2'T6 '—�CP�'�Z-s PARCELSI'/.E (✓.17-7 o <br /> I OWNER NAME �IarlGt �A PHONE <br /> c <br /> OWNERADDRESS "td']`�_ (� �-0ot-0.t\(�'Q K,� -• I CIT"/STATE/ZIP "/r C.L{ CC_ —{ � <br /> CONTRACTOR '" PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> 1 <br /> LICENSE ❑C-42 ❑C-36 OTHER __ NUMBER EXPIRATION DATE _ <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST' #' BUILDING PERMIT# O/S'P'a.AND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS.' NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> SEPTICTANK TYPE/MFG `I' ��-- CAPACITY Ci�+O gal #OFCOMPARTMENTS ~ <br /> LI GREASE TRAP TYPE/MFG CAPACITY .gal #Of COMPARTMENTS .r <br /> I <br /> L) PKC TX PLANT DISTANCETO NEAREST:.WELL SO IA..twR FOUNDATION ft PROPERTY LINE ft <br /> �❑3 LIFT STATION SIZE TYPE OF PUMP ,r ❑ ,SAND OIL SEPARATOR(ENcLosED SYSTEM) (� <br /> 18t LEACH LINES LILEACHING CHAMBERS #OF LIES 3. LENGTH OF LINES l oo <br /> DISTANCE TO NEAREST WELL. 5Q Iftt FOUNDATION ft PROPERTY LINE R <br /> 11 ❑ FILTER BED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE nl ft 1V <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft t� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> 13 sumps WIDTH R LENGTH ft DEPTH R <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 1 <br /> O DISPOSAL PONDS WIDTH R LENGTH ft DEPTH ft O <br /> ' .DISTANCE TO NEAREST. WELL ft FOUNDATION It PROPERTY LME ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH t ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE tl ` <br /> E1 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 /> MINIMU TOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE.CALL(209)953-7697 1 <br /> j <br /> SIGNED00 <br /> e <br /> 5 <br /> _.4L'/ <br /> Z,,Jk: 'SJ35 <br /> o <br /> F, a t° q ! HZZU f RE OT <br /> A a 5c M <br /> SAN <br /> H <br /> T <br /> mPitlump <br /> Application Accepted By' DateArea Employee IFinal Inspection By Dxte_ ❑ SPECIAL PERMIT-Approved by <br /> Character or Soil to Depth of 3 Ft: Character: <br /> COM TS <br /> 11 11"IZ-4 ° <br /> TOT.,• � /Z _ <br /> PE SC Received cc" Amount Date Permit/ invoice# Permit ID# <br /> Code INFO B - xs Remitted Service Request# - <br /> If2 t! !►7 <br /> 42.02.001 - - - ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />