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jZ; 3D <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDAB E ERMIT CALL 209 95 -7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z4XZ ` CITY/ZIP V, <br /> 1 <br /> 17DU <br /> CROSS STREET � � (�- API —14 1 PARCEL SIZE 4T Ae- p <br /> OWNER NAME �� !! // <br /> l© 7� PHONE �✓� <br /> A �^ <br /> OWNER ADDRESS �"9 ~',`s r,�:��._12-n CITY/STATE/Z1 <br /> CONTRACTOR 96t,45 WC— PHONE Q <br /> CONTRACTOR ADDRES. nV CITY/STATF:/ZI <br /> LICENSE C-42 ❑C-36 OTHERno NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEWIN.STALLATION REPAIR/ADDITION ❑ ENGINEERDESICNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHE <br /> NUMBER OF LIVING UNITS: NUMBER Of BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTAN'K TYPL/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPF/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP QQ/^ L3SANDOIL SEPARATOR(ENCLOSED SYSTEM) <br /> /" <br /> LEACH LINES LEACHING CHAMBERSC4F /T 6 N OF LINES LENGTH OF LINES R <br /> DISTANCE TO NEAREST WELL �ft FOUNDATION ft PROPERTY LINE ft / \ <br /> ❑ FILTER BED WIDTH fl LENGTH R DEPTH ft I\ ' <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINT it <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEARFST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> �[ SUMPS WIDTH_ft E//rJ�,jyyiFJJi�Y`` I y� Fl DEPTH ft <br /> DISTANCE TO NEAREST WELL 6b: ft FOUNDATION © ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH Il DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> LI SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IV ACCORDANCE WITH SAN JOAQUIN COON"TY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> C 'I7E <br /> V ti( NOTICE REQUIRED FOR L E I H1 NS-PL i.1,(209)953-7697 <br /> SICNE 11 TT L IDATE46_1 WIC) <br /> r <br /> r- r <br /> ©Q <br /> IV <br /> Gi <br /> 1 - - <br /> !":)N <br /> 01 <br /> Application Accepted Date Area Employee IDN 7 / <br /> Final Inspection By _ Date 0 ❑ SPECIAL PERMIT-Approved 6y <br /> Character of Soil to Depth of 3 Ft: Pil/Sump Soil Character: <br /> COMMENTS 1 IL l la 19 MaU <br /> PE SC eceived Chec Amoun Date Permit/ Invoice# Permit lDN <br /> Code INFO B .ash Remitted I Service Request# <br /> G S <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 1-222,2003 <br />