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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-(269)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-76697 FOR IVSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 120 IV- 6rrje r . CITY/ZIP LA <br /> D ) M <br /> • CROSS STREET �()T{Id(� APN r -l�D- G PARCEL SIZE <br /> OWNER NAME Til p�/� l/y".�' PHONE 2�7 '^h32 I-'77!7 y <br /> OWNER ADDRESS Z/2 W. PA1 14WI7 re P r l/ CITY/STATEIZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: C00rdinate9 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 /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: /f NUMBEROFEMPLOVEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY RQV gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION R PROPERTY LINE ft , <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES At LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH it <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL. ft FOUNDATION ft PROPERTY LME ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft <br /> • DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE R <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 /> UR ADVANCE N(YITCY,REQUIRED FOR INSPECTIONS-PLEASE CALL.(209)9;3-76')7 <br /> SIGNED + TITLEDAWP)01% DATE r/Z <br /> t. <br /> 1.11 QL <br /> b <br /> N <br /> f 'ME qTjL <br /> D PAI ITh <br /> r <br /> DEPARTME�N � �pNr <br /> Application Accepted B Datei $+pry A(ea &e` Employee ID# <br /> Final Inspection By Da ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS II-$-7euS-- S ke,0&i)ee6 774Ak7 UAJ ocgpA D- X E,�e4Wk,e <br /> F/AIAt ✓� —4L,MiA) . C.+LZ Fdre E,iJS,'67e7-1 of _—_-_-- <br /> __ ........_._.. <br /> PE SC Received CheeLWJ,— Amount Permit/ <br /> Code INFO B Cash Remitted D to Service R nest# Invoice# Permit ID# <br /> 42-02-001 <br /> 12/2212003 ONSITE WASTEWATER PERMIT <br />