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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT / <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART. 304 E WEBER AVE-3Y°FL-STOCKTON � (209)468-3420 <br /> NON-REFUNDABLE PERMIT CA 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEA-KrROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> CROSS STREET I APN 41 -//PARCEL <br /> N,SIZE`Cy p <br /> OWNER NAME I ` LLT <br /> PHONE _JlY 1 w <br /> OWNERADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS 4999 1 - CITY/STATE/ZIP (y► <br /> LICENSE ❑C42 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X }' <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# - <br /> TYPE OF WORK: 7 NEW INSTALLATION ElREPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE I <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER - <br /> },( NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> 1>0 SEPTIC TANK TYPE/MFG &ry- RA,-L_ CAPACITY _ gal #OFCOMPARTMENTS� <br /> ❑` GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL V O ft FOUNDATION '57--ALL ft PROPERTY LINE .5 ft <br /> ❑ LIFT STATION SIZE TvPE OF Pump ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> �A/J}A�)I <br /> LEACH LINES Ll LEACHING CHAMBERS #of LINES� LENGTH OF LINES VIV ft <br /> DISTANCE TO NEAREST WELL_ft FOUNDATION 5e-) —ft PROPERTY LINE fl <br /> ❑ FILTER BED WIDTH it LENGTH ft DEPTH tl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH it LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LME it <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LME ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER � WIDTH�1 t1 DEPTH ft <br /> DISTANCE TO NEAREST WELL 4C R FOUNDATION_5 A PROPERTY LINE fl <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE 1N ACCORDANCE WITH SAN JOAQUIN COUNTY ` <br /> ORD]' NCES,ST TE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> NI 1 UM 24 UR AD NCE NOTICE REQUIRED FOR INS ONS-PLEASE CALL(209)953-7697 <br /> SIGNEDGq? TITLE DATE C) "I2-�7 <br /> T <br /> NG kl `1�'�►� �Llv.p <br /> '�`aY,(A Talmo /MHJ i�ArAp "- L <br /> M�+y <br /> R7 E <br /> w)-raJ,l; <br /> I� wca-� <br /> A& ------ <br /> DEPARTMENT USE ON 1' <br /> .Application.Acce Date <br /> :=DEPARTMENT USE <br /> Area Employee ID# 5� <br /> Final Inspectio Date /rS�7 ❑ SPECIAL PERMIT- pproved by <br /> Character of Soa to Dep of 3 Ft: P]USump Soil Character: .� <br /> COMMENTS <br /> -z3�_ (� <br /> d <br /> PE SC Received Chec Amount Date Permit/ q <br /> Code INFO By Cash Remitted Service Re uest# Invoice# Permit ID# <br /> c �. <br /> 42-02-001c�_��c <br /> 1222/2003 i� '-r! F \ x C-Pii'6ff{f XEWATER PERMIT <br />