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G ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUWCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT A CALL 209 953-7697 LOR INSPECTIONS EXPIRES I YEAR FROM D <br /> JOB ADDRESS CITV/ZIP Jaffj <br /> r CROSS STREET VATf fah APN � �� �O L PARCELS <br /> S17E e o <br /> OWNER NAME PHONE <br /> OWNER ADDRESS L9 I 15"0kAl 6 CITY/STATFIZIP OTQVATo <br /> CONTRACTOR ID 6lW PHONE <br /> CONTRACTOR ADDRESS wj— CITY/STATE/ZI <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 ❑ ENGINEERDESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: �.J NUMBER OF EMPLOYEES: <br /> X41 SEPTICTANK TYPE/MFG1rP^Af-3T-ft-,1& CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG _ CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL H FOUNDATION R <br /> A PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP _W"/SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ' S LEACHING CHAMBERS # F LINES 45 LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOIANDATION ft PROPERTY LINE, <br /> t 1 /�� <br /> FILTER BED WIDTH /�o ft "/ <br /> LENGTH V DEPTHfj'Js�T <br /> DISTANCE.TO NEAREST WELL 50+ ft FOUNDATION 'SjOT ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH fl LENGTH it DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL it FOUN'DA1'ION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH ft Q <br /> DISTANCE TO NEAREST WELL 11 FOUNDATION ft PROPERTY LME fl <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION tI PROPERTY LIFE ft <br /> r <br /> 1 HEREBY CERTIFY THAT I HAVE.PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY 1`1 <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> NI M NOTICE REQUIRED FOR INS 'C�PLE 2091 953-7697SIGNE hr=11 TITLE DATE Y � <br /> AW <br /> 0 <br /> i <br /> p a ' <br /> 1 <br /> DEPARTMENT US ON Y HEALTH DEPARTMENT <br /> Application Accepted By X't Date O QS Area Employee ID# c CIL q� <br /> Final Inspection By _ Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft Pi/Sump Soil Character: <br /> COMMENTS pmt) La'r e—,6 cc i <br /> D K <br /> PE SC Received Chec Amount Date PermiV Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> 42.14 �lS t,6 -4 N !-3C"L) D/&/65,6�c00 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12822003 <br />