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ONSITE WASTIATER TREATMENT SYSTE,,,.w?ERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"'FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALI, 209 953-7697 FOR INSPEA TIONS EXPIRES I YEE{ARR FROM DATE ISSUED <br /> t �, 2 <br /> CIT}'/GIP 1J I I /Z 40 � <br /> Joe ADDRESS ;�Ll ['� <br /> CROSS STREET K��?.I \�1 1v IPA - APN Q_ i9 �19 J PARCEL SIZE <br /> OWNER NAME ^^� v S I/�� �f PHONE r <br /> OWNER ADDRESS •�`/�� �T�V ` C� -� - CITY/STATE/LIP URNO 1 <br /> CONTRACTOR l7 �L�l"v PHONE. <br /> CONTRACTOR ADDRESS CITY/STATE/LII' _ <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DFP"TII: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> oq <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# — <br /> TYPE OF WORK: ❑ NEW INSTALLATION LlREPAIR/ADDITION LJ ENGINEER DESI,C,N�ED/ALTERNATIVE <br /> ❑ REPLACEMENT DESTRUCTION �•� <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF 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 /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF-j.INES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ION ft PROPERTY LINE ft <br /> EI FILTER BED WIDTH ft NGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL UNDATION ft PROPERTY LINE t <br /> ❑ MOUNDED WIDTH tl LENGTH fl DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> 1 <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 Il FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELT. 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 /> MINIM 1111 24 11111111 A ANCE NOTICE REQJARED FOR INSPECTIONS-PLEASE;CALL(209)9$3-7697 <br /> SIC.NED TITLE_A�:qj.e+/1T DATE 5 <br /> XSI <br /> CIA iij, <br /> J <br /> E VII O M NT L <br /> DEPARTMENTS NLY <br /> Application Accepted By Datc J Area Employee ID# <br /> Final Inspection By Date a/ ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO 13v Cash Remitted Service Request# <br /> z 7 alb oS5 Ll <br /> 42.02-001 ONSITE WASTEWATER PERMIT <br /> .2'2001 <br />