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` fl ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOA UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3R'FL-STOCKTON A - _C 95202 (209)468 3420 <br /> NON-REFUNDABLE PERMIT nCALL 2091,9553-7697 FOR INSPECTIONS `EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �.L (r� v G C{ V�.C� CITY/ZIP- JX6 CkrJA) 95624 <br /> CROSS STREET <br /> A ^/ APN TO O D PARCEL SIZE (/ o <br /> OWNER NAME -'T F O�S PHOI 4" V�J <br /> p <br /> OWNERADDRESS `-' CITY/STATE/ZIP AM411 t$ <br /> CONTRACTOR TCC L i PHO <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP C <br /> LICENSE ❑C-42 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: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> 3 <br /> NUMBER OF LIVING UNITS: 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 /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ff <br /> 111❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> yp LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> \ / <br /> DISTANCE TO NEAREST WELL 5 D t ft FOUNDATION 30 ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ff <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUN TION ft PR ERTY LINE $ <br /> SEEPAGE PITS NUMBER I WIDTH 31�41 ft DEPTH ft <br /> DISTANCE TO NEAREST WELL / b0� ft FOf NDATION �gd ft OPERTY LI ft <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 /> vM✓I�NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED e / T OLu Iy LE y L_ DATENz <br /> —a _6 <br /> b <br /> LAt,I I I i LEVL <br /> 10 <br /> t <br /> 1 <br /> t <br /> zt <br /> � 00 <br /> 0 <br /> Q 1N C <br /> N�R M • t✓ <br /> � L <br /> �. lof <br /> Tr- <br /> DEPARTMENT S OApplication Accepte Date 2iArea Employee ID# <br /> Final Inspection By Date i ❑ SPECIAL PERMIT-A rov pp ed byCharacter of Soil to Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ <br /> Code INFO B Remitted Service)Request# Invoice# Permit ID# <br /> Z ` 103 <br /> 42-02 01 <br /> I2/22/2003 <br /> ONSITE WASTEWATER PERMIT <br />