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ONSITE WASTEWATF-R,TREATMENT SYSTEM PER.) <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"°FL-STOCKTON CA 91 (209)468-3420 <br /> F NON-REFUNDABLE PERMIT CALL(209)Y53-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> / <br /> E JOB ADDRESS CITYIZIP /C <br /> Ir <br /> APN PARCELSIZE <br /> CROSS STREETf 3,� E 2-5 <br /> A <br /> OWNER NAME '[�!{ PHONE .. <br /> OWNER ADDRESS CITYISTATE?ZIP <br /> I FCONTRACTOR 4 r G PHONE <br /> f <br /> CONTRACTOR ADDRESS CITYISTATEtZtP <br /> LICENSE C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br />' F <br /> WATERTABLEDEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIRIADDITION O ENGINEER DESIGNED(ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTIONS <br /> FINSTALLATION WILL SERVE: RESIDENCE E3 COMMERCIAL ❑ OTHER <br /> S ' <br /> NUMBER OF LIVING UNITS: // NUMBER OF BEDROOM / _ NUMBEROFEMPLOYEES: <br /> ❑ SEPTICTANK TYPEIMFG �L. CAPACITY eeW.. gal #OFCOMPARTMENTS <br /> E ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTSy, <br /> ❑ PKG TX PLANT DISTANCETO NEAREST: WELL__ ft FOUNDATION t ft PROPERTY LINE >+ ft , <br /> ❑ LIFT STATION SIZE TYPE OF PUMP -❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS_ .'J #OF LINES /o -_ LENGTH OF LINES So r T ft(l� <br /> DISTANCETO NEAREST WELLft FOUNDATION ! Q ft PROPERTY LINE _ A <br /> ❑ FILTER BED WIDTH ft LENGTH - ft DEPTH ft <br /> DISTANCE TO NEAREST WELL—A FOUNDATION ft PROPERTY LINE ft <br /> CI MOUNDED WIDTH ft LENGTH ft DvPTH ft <br /> DISTANCE TO NEAREST WELL ft FOONDATION ft PROPERTY LINE R <br /> ❑ Skimps WIDTH 0z fl LENGTT-H-77 �•� ft DEPTH <br /> 1512 �r R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ! 0 _ ft PROPERTY LINE ';f` ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <br /> iH ft \ <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q SEEPAGE PITS NUMBER WIDTH A DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> - I HFREBV CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIN�SNCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2(19}953-707 <br /> SIGNED TITLE DATE <br /> DATE <br /> Fs <br /> ti <br /> to I I YI } <br /> X LN <br /> iI <br /> vu <br /> A_ <br /> ,r r <br /> U llc ,s ll' <br /> F1 - NV ROM <br /> DEPARTMENT US ON Y <br /> F Application Accepted B bale Area T Employee IDN <br /> I Final Inspection By '-r lti,- .I Date T—�) x.1: .5 I3 SPECIAL PERMIT-Approved by <br /> Character of Soil to p'(h of 3 Ft: Pit1Sum p Soil Character: <br /> COMMENTS 41/41/ /)M— Z <br /> F! PESC Received Cheek#! Amount Date Pe mill <br /> lnvoice# Permit ID# <br /> Cade INFO 8 ash Remitted Service Re Uest# <br /> 7;)-3 b a 5(�'cG yz'7 <br /> L 4242.001 ONSITE WASTEWATER PERMIT <br /> 12/2272003 <br />