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i <br /> 10 <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -340 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS �� 4 J a C it l SM AIV a CITY/ZIP S LA <br /> CROSS STREET L11�l L1� APN Z3-uo - 06 PARCEL SIZE_�_ a <br /> '�V 0 OWNER NAME Ai b—I C A i:j Ek/A1V 0C-Z PHONE 9, (1—g 7 9 � <br /> OWNER ADDRESS S&M 1_ CITY/STATE/ZIP y <br /> CONTRACTOR PHONE �� 2 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> 71 <br /> LICENSE C-42 ❑C-36 OTHER NUMBER <br /> EXPIRATION DATE 31 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 'C <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: 0 RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG 2-O �/� bTr({iYf;��ppgCITY gal #OF COMPARTMENTS _ <br /> G� GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE $ <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> �. LEACH LINES ❑ LEACHING CHAMBERS 10� <br /> #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION- $ PROPERTY LINE S 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 LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft 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 /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I 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 /> M 4 H A E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE_ �u,/IJ1 DATE <br /> 3k&--O <br /> �i <br /> M Q 0\ <br /> O Q <br /> 7 7117-77, - SNL- <br /> r <br /> 3 <br /> DEPARTMENT .' O, <br /> Application Accepted By Date Area Employee ID# -- 9 <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De th of 3 Ft: It/Sump Soil Character: <br /> COMMENTS <br /> IRZ <br /> PE SC eceived Check#/ Amount Permit/ <br /> Code INFO B Remitted Date Service Request# Invoice# Permit ID# <br /> Zl v 11 Z-W '" yz3 D 3 <br /> 42-02-001 <br /> 12/22/2003 ONSITE WASTEWATER PERMIT <br />