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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)46&3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 9 !��/E� � ,� �jj� �1 Crry/ZIP 41cagg <br /> CROSS STREET APN fl� :376/2— PARCEL SIZE <br /> 0 <br /> OWNER NAME A <br /> PHONE <br /> OWNER ADDRESS1,1 •• CITYISTATE/ZIP <br /> CONTRACTOR <br /> PHONE 3 -SO <br /> CONTRACTOR ADDRESS -14ALECITY/STATE/ZIP <br /> LICENSE C-42 ❑C-36 OTHER_ NUMBER n EXPIRATION DATE 4 C <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X V <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBEROF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY /6,02_ gal #OF COMPARTMENTS_ <br /> ❑ GREASE TRAP TYPE/MFG �•""�� CAPACITY gal #OF COMPARTMENTS <br /> i❑ Q J PKG TX PLANT DISTANCE TO NEAREST: WELL /yo R FOUNDATION 7 R PROPERTY LINE /ad R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) JAI <br /> �/ C� <br /> LEACH LINES LEACHING CHAMBERS �9� J <br /> #OF LINES 3 LENGTH OF LINES To ft <br /> DiSTANCETO NEAREST WELL—Wo f[ FOUNDATION _ft PROPERTY LINE S ft N <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE 11 <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft (� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH ft ?- <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> tx SEEPAGE PITS NUMBER �WIDTH_ 3 ` ft DEPTH EZS` ft <br /> DISTANCE TO NEAREST WELL POOP ft FOUNDATION 70 R PROPERTY LINE <br /> 1 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE.CALL(209)953-7697 // n <br /> SIGNED— � � TITLE DATE 9/6�k {- <br /> 3 <br /> DEPARTMENTUSE <br /> Application Accept Date C.6 Area Employee ID# <br /> Final Inspection y Date /– ❑ SPECIAL PERMIT-Approved <br /> Character of Soil to Depth o 3 Ft: PiU mp Soil Character: — <br /> COMMENTS <br /> �J <br /> PES <br /> Received AmountDate ice PCrmRit/nest# Invoice# Permit ID I <br /> Code INFO B Remitted Sery <br /> 2-1 Q- S 1200 <br /> 42-02.001 <br /> 12/22/2003 ONSITE WASTEWATER PERMIT <br />