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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 /> JOB ADDRESSCITY/ZIP <br /> CROSS STREET APN I ( J L^(J Q PARCEL SIZE <br /> v <br /> --nN V PHONE b al—a Igo <br /> OWNER NAME �1 <br /> OWNER ADDRESS -< , ' A CITY/STATE/ZIP Y-4A*1e, <br /> CONTRACTOR 4 aC PHON <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP7-A 1�1�i7lj <br /> LICENSE ❑C42 -36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEERDES NED/ALTERNATIVE <br /> 13 REPLACEMENT � DESTRUCTION ItiC <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE MMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF EDROOMS: NUMBER OF EMPLOYEES: <br /> 1d SEPTIC TANK TYPE/MFG C(�L CAPACITY gal #OF COMPARTMENTS C <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENT$ <br /> ❑ PKC TX PLANT DISTANCETO NEAREST: WELL ft FOUNDATION R PROPERTY LME —Zl')R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) in <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> FILTER BED WIDTH �21i- 3S ft LENGTH 32- y DT R DEPTH 3 15- ft <br /> DISTANCE TO NEAREST WELL R D <br /> FOUNDATION R PROPERTY LINE R <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LME R <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R 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 IV ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> . I M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNE TITLE 17WIliJe2Z DATE <br /> ¢fqlag IN CC UN ry <br /> N <br /> v <br /> Y n <br /> i <br /> DEPARTMENT US ON <br /> Application Accepted Date Area Employee ID# ���l/ <br /> Final Inspection By I �'3PECIA IT-Approved by �/ <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS i <br /> lD�f�i d <br /> �F`71 ;P�l�i cfsz-f�t� fl�iticzc4 9r_- /� w <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted I Service Request# <br /> f ' I 7 l (l'4 0 �fSD 2A 05 <br /> 2 Ze L boy <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />