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ONSITE WAS)WATER TREATMENT SYSVI PERMIT <br /> SAN JOAQUIN COUI TV ENVI['bNMENTAL HEALTH DheARTMENT 304 E WEBER A. -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> { <br /> JOB ADDRESS {C✓k,ub', ISL D <br /> CITY/ZIP <br /> ( dCROSSSTREET APN <br /> OWNER NAME A <br /> t�. /7 �1 PHONE ,`T- L1 C)& <br /> OWNER ADDRESS �_s kc"_ L..� LDL 2 0 CITVISTATE/Z]P__ <br /> CONTRACTOR L jd` PHONE "L.L -L 0 6j <br />`r <br /> CONTRACTOR ADDRESS 9E� . 2k)QfC CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE k3l(Y <br /> WATER TABLE DEPTH: ( t <br /> j1,;,? Ac- NUMBER <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> �❑ PERC TEST # BUILDING PERMIT# + LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: !FIRESIDENCE ❑ COMMERCIAL�j ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES' <br /> Zr'SEPTIC TANK TYPE/MFG Pi , -CAPACITY 124r.-IO gal #OF COMPARTMENTS__ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS ^ 1 <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ,V <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) n' <br /> — I <br /> Li—/LEACH LINES ❑ LEACHING CHAMBERS � W #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH ft <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 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 NUMHER WIDTH ft 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 /> I <br /> INI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED..,. TITLEDATE 5 ` <br /> I <br /> J 90-WS-3 <br /> i <br /> E <br /> 1 i <br /> Ii <br /> I <br /> LL1411 itP <br /> gf- q <br /> DEPARTMENT U E O�LY �s `! N!Application Accepted By Date �� Area 1 ® Employee ID# <br /> Final Inspection By � 'x /Qa4Date � f <br /> � ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS _ .� OL-6 L-VT O F 0-140 /f ,4-673-3- '&s_05 �ff'lfti`ea l t';a 76 AA M) <br /> � w!'J/�1/�Lc <br /> �.t'}/'us%�J�' /.•� ,I ° �� '�j[ �d:f`o'�/ /A,'5V '�- ' ',/'fJ%.� ✓Y'?:;/N /r'�v'� e(�f',.. S� r <br /> PE SC Received Check#/ Amount Permit! <br /> Code INFO By Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 42, 11 17 �W <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/2212003 <br />