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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> ,- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT 304 E WEBER AVE.-3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDAB RMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CITY/ZIP r 2- <br /> C.O. <br /> CROSS STREET C T481Wf rUb > <br /> API ( PARCELSIZE I G <br /> . <br /> -4194- <br /> 4 1 /4 w F <br /> OWNER NAME y <br /> PHONE <br /> OWNER ADDRESS 5 3FtL111'/STAT1LI1 <br /> CONTRACTOR \/- <br /> v 1 <br /> PHONE <br /> CONTRACTOR ADDRESS , CIT\'/$TAI T+'F/21P1 � M�� r <br /> LICENSE C-42 ❑C-36 OTHER A- _ NUMBER � r" EXPIRATION DATE <br /> WATER*TABLE DEPTH:_ fl GEOGRAPHICALINFORMATION: Coordinates X _ Y <br /> Z] PERC TEST(S) NUMBER LAND USE APPLICATION 4 -� <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DMIGNED/ALTERNATIVE <br /> ❑ REPLACEMEN-1- ❑ DESTRUCTION C <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER_ <br /> NUMBEROF LIVING UNITS: NUMBER OE BEDROOMS: 4 NUMBEROT EMPLOYEES: <br /> LISEPTIC TANK TYPO/MFG -711/S 1t'1; , <br /> `YJI�CAPACITY go[ V OF COMPARTMENTS <br /> �s <br /> Z) GREASE TRAP TYPE/MFG ff CAPACITY gal p OF COMPARTME\TS `- <br /> ❑ PKC TX PLANT DISTANCETO NEAREST: WELL _ ft FOUNDATION tt PROPERTY LINE_ fl <br /> ❑ LIFT STATION SIZE TYPE OF/P�UMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES *11 LEACHING CHAMBERSF- 6 It OF LINES 1 _ LENGTH OF LINES X42- tt ` <br /> DISTANCE TO NEAREST WELL -� tt FOUNDATION 12 PROPERTY LINE 7LJ_ ft "J <br /> ❑ FILTER BED WIDTH ft LENGTH - R DEPTH R c <br /> DISTANCE TO NEAREST WELL_ ft FOUNDATION ft PROPEHIY LINE R <br /> ❑ MOUNDED WIDTH R LENGTH _ _ft DEPTH It <br /> - DISTANCE TO NEAREST WELL It R <br /> �fFOOUNNDATION R PROPERTY LINE <br /> SUMPS WIDTH f— ft LENGTH /1 t /R� DEPTH <br /> DISTANCE TO NEAREST WELL + ft FOUNDATION ft PROPEKIY LINE i tl <br /> DISPOSAL PONDS WIDTH _ It LENGTH ft DEPTH _ R <br /> _ DISTANCE TO NEAREST WELL ft FOUNDATION 11 PROPERTY LINE Ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE }t <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS.APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAW'S AND RULES AND REGULATiONS OF SAN JOAQUIN COUNTY, <br /> A'((��{,,t INT V,�ICE NOTICE REQUIRED FOR I(�$ E L1NS-P CALL(309)953-7697 <br /> SIGNED TITI-Ilt DATE�ls _ <br /> ' I <br /> � A <br /> \ U <br /> PA tP <br /> JY 5' 4 <br /> L IT <br /> I N � <br /> .. <br /> DEPARTM NT USE ONLY ` 0 <br /> Applitation Accept _ _ Date 6Area r Employee lDN_ O <br /> Final Inspeetion y _ _ _ Date [7 2�8 ❑ SPECIAL PERMIT-Approvrd by <br /> Character of Soil Iopth of 3 Ft: _ - Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ AmountDate Permit/ Invo' p Permit IDN <br /> Code INFO 8 bash Remitted Service Re uestq <br /> ('fit iIs 1 i C 6R CO 3 <br /> 42-01-00I ~ ONSITE WASTEWATER PERMIT <br /> 12/2/02 <br />