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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 301 E WEBER AVE-3-PL-STOCKTON CA 95202 -(209)468.3426 <br /> NON-REFUNDABLE PERMITr,�-- CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> YOB ADDRESS U ��7 a CITYIZIP_ L n ' <br /> CROSS STREET > <br /> APN p - OZl PARCEL SIZ�EI I e <br /> OWNER NAME £L­� ' Pe PHONE <br /> OWNERADDRESS I <br /> I, C17y/STATFIZIP <br /> CONTRACTOR 0 D <br /> PHONE 3u <br /> CONTRACTORADDRESS D Z. '— CITYJSTATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH:_ ft GEOGRAPHICAL INFORMATION: Coordinates k y <br /> PERCTEST #, IT# LAND USE APPLICATION CPU <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: NUMHER OF EMPLOYEES: <br /> 1 <br /> ❑ SEPTIC TANK TYPF/MFG_ CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/mFG— CAPACITY gat #OF COMPARTMENTS <br /> Cl PKG Tx PLANT DISTANCETO NEAREST] WELL R FOUNDATION _ ft PROPERTY LINE ft 0 <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES___ LENGTH OFLTNES R <br /> DISTANCE TD NEAREST WELL R FOUNDATION_ ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH 8 LENGTH _R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH fr <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION ft PROPERTY LINE ft <br /> Q DISPOSAL PONDS WIDTH ft LENGTH_ ft DEPTH ft <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMRER WIDTx ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LME R <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE MINE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 21 HOUR ADVANCE NOTICE REQUIRED FOR iNSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED - - TITLE_ DATEFklvv'A�° a <br /> III IF-TT-T-1 <br /> - 1 <br /> adL V <br /> N1 17- <br /> N OQiN <br /> E T <br /> ,./ DEPARTMENT USE ONLY � 6:= /OV <br /> Applicati..IA,, d Btip---'-- /- 78 2' ,1 r <br /> ApplicatiDBd B to�� rZ Area Emplo�:��Z.yce IDI! 5qqq <br /> Final Inspection By Jute h��fl _ ❑ SPECIAL PERMIT-Approved by_ <br /> Charncterol Soll to Dept of3 Ft: PRISUmp Soil Character: <br /> COMMENTS <br /> PE SC Received Check#I Amount Permit/ <br /> Code INFO B• Remilled Date I+voke# Permlt ID# <br /> S-2.2 <br /> 62-02-001 <br /> 1 12'2212003 ONSITE WASTEWATER PERMIT <br />