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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)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / --� �� Y- =i S - � ¢... �` .-� CITY/ZIP ).._ •-> ;� , <br /> CROSS STREET a C Y` F �' �""� � c-` APN i•--kh f 7'- � 1 PARCEL SIZE <br /> OWNER NAME PHONE .-')('!-. <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> V CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE q <br /> Now WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y t-Yt •r' - ti(f <br /> ' PERC TEST # BUILDING PERMIT# LAND USE APPLICATION#,�p o <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNA'TIVE <br /> j ❑ REPLACEMENT ❑ DESTRUCTION <br /> 2�t INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBEROF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZe TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 6w ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE it <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 60 ❑ MOUNDED WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft 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 /> i MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> 1 <br /> SIGNED"�-i-- � TITLE t l-2. �-- DATE <br /> VAR <br /> it <br /> it <br /> IVED <br /> I <br /> ftr i <br /> t'L• I <br /> } i s <br /> i t <br /> R N E <br /> jf3ar RT E <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Ili(!"? ,1 —'�--�-'7! Date e-) �ry -� � [�. Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by , <br /> r Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/j} Amount Permit/ <br /> Code INFO B C—SB~J Remitted Date gervice Re uest# Invoice# Permit ID# <br /> low 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />