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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-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CC CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS /�tJY� J I J CRY/ZIP rn <br /> Q m <br /> CROSS STREET w APN I Z� 1,-f'010 PARCEL SIZE , yj O <br /> OWNER NAMEPHONJ, c� Yy..?• <br /> OWNERADDRESS LO p(3/fqI /'K V `''/uC CITY/STATE/ZIP,'4 ZI ctiA•- CA. 9S-..21r' <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATFJZIP <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 ❑ EN (NEER DESIGNED ALTERNATIVE <br /> O REPLACEMENT DESTRUCTION �' <br /> INSTALLATION WILL SERVE: (3 RESIDENCE ❑ COMMERCIAL ❑ HER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY 891 #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY Bal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCETONEAREST: WELL ft FOUNDATION R PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES O LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft (� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE fl <br /> O FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH ft O <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH it DEPTH ft <br /> • DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> O SEEPAGE PITS NUMBER WIDTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I 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 /> MINIMUM 24 HODU ADV/ONCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED 74TITLE ILA Cj" - DATE dr—C7 Cr <br /> I <br /> 01, <br /> O <br /> M <br /> E <br /> 01 I'll <br /> 7-771 <br /> E TMENT USE 'LYApplication Accepted Accepted By Date Area Employes ID# <br /> Final Inspection By z, Date [-,/iy >/O-;e [3 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 t: Pit/SumR Soil C4araeter: <br /> • COMMENTS <br /> F !j s <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By s Remf Service Re uest# <br /> 2 07 1 v �i <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/222003 <br />