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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)469-3420 <br /> NON-REFUNDABILEPERMIT CALL 2{009 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRoM DATE ISSUED <br /> jtS1�__ <br /> JOS ADDRESS -3 IJ(.-) + �� <br /> � A + '� CITYIZIP Kj <qcZ5c!�bL7 � <br /> CROSS STREET T 1`f` APN PARCEL SIZE > <br /> OWNER NAME PHONErte„ <br /> "� _ <br /> OWNER ADDRESS L.J�Q CJ ¢--�1 Pt � �1- t CITYIS,TATEIZIP v�LC { C <br /> CONTRACTOR } I W PHONE <br /> CONTRACTOR ADDRESS CITV/STATEIZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: L3 NEW INSTALLATION ❑ REPAIR/A ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> 0 REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CA.VVs <br /> rr❑ GREASE TRAP TYPE/MFG CAP�A''C�IT ! FC[ 1Ff <br /> OJ <br /> ❑ PKGTXPLANT DISTANCETONEAREST: WELL ft FoUNDAPef Wexpftd*ARWut ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP work b9in "FAWN"A OSYSTEM) <br /> 1 Health IVISIE n <br /> L3 LEACH LINES ❑ LEACHING CHAMBERS #Mx S LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH it LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL, It FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> G7 SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE 6t <br /> 1 HEREBY CERTIFY THAT 1 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 <br /> SIGNED _ TITLE DATE <br /> i <br /> H UI C U <br /> N iR N <br /> H <br /> r PARTMENT JJSE ONiY <br /> Application Acceptedy Date Area Employee 1D# <br /> Final Inspection By Date 11SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS +L� <br /> LAzl- z A 1,05r a <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B as Remitted I Service Request# <br /> Zl — n'00 I -767 <br /> 42-D2-001 Sit&c e 4C L� . sit Lam` ,rlf2_ G4/Y q"4zf a#P&:TGLr-th 4' oNsA ER PERMIT <br /> 1222/2003 <br />