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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 /> j/ <br /> JOBADDRESS !/W � " I�� CITY/ZIP ITY/ZIP <br /> �) \ -1 <br /> O <br /> API PARCEL SIZE 3 ,/� ov <br /> CROSS STREET �����["" _G.S�� �--} 9�L— /�/` A <br /> OWNERNAME —„ 6��I �S�i/, � LIAl _ PHONE _ Ll yy <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR 25� PHONE J <br /> CONTRACTOR ADDRESS CIN/STATE/ZI I <br /> LICENSE -42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y— <br /> D <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION 35- <br /> REPAIR/ADDITION L) ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE *COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: �I/ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES <br /> ft � <br /> DISTANCE To NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ SUMPS WIDTH ft LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH. ft DEPTH ft <br /> DISTANCE TO NEAREST WELL / ft FOUNDAMT, �' ft <br /> PROPERTY LINE ft <br /> ft DEPTH <br /> SEEPAGE PITS NUMBER WIDTH ,./ > <br /> DISTANCE TO NEAREST WELL f `I ft FOUNDATIONft PROPERTY LME TO ft <br /> I HEREBY CERTIFY THAT 1 HAVE <br /> ORDINANCES,STATE AWS AND RULES ON AND THE WORK WILL BE NWITH SAN JOAQUIN COUNTY <br /> RULES AND REGULATIONS OF SAN JOAQUIN COUNTYW <br /> MINIMUM 4 HOU MANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE _ DATE <br /> Ll iL <br /> E <br /> ul <br /> rP 14 <br /> DEPARTMENT U, O, LY G(fluz, <br /> Date O Area Employee ID# p <br /> Application Accepted B I /r <br /> Final Inspection B - Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to th of 3 Ft: PIUSump Soil Character: <br /> COMMENTS <br /> s ) i ct-Gt�n ns nv\ 5/Z�/ cam ' <br /> PE SC Received h Amount Permit/ I.Volc.# Permit ID# <br /> Code INFO B Cash Remitted <br /> Dale Service R utst Is 11 <br /> 2/ 25-(j &Z/ 3�U <br /> ONSITE WASTEWATER PERMIT <br /> a2-02-001 <br /> 12222003 <br />