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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)468-3420 <br /> j NON-REFUNDABLE PERMIT '( CALL(209)953-7697 AOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> II JOB ADDRESS CITY/ZIP I .�).t' <br /> CROSS STREET APN J' O l:C� PARCEL SIZE 1 p <br /> v <br /> OWNER NAMEPHONE <br /> 1 .Jl m <br /> OWNERADDRESS !') \ ` \- —!.� 1', CITY/STATE/ZIP <br /> CONTRACTOR 'ice PHONE \I: I <br /> I <br /> CONTRACTORADDRESS CITY/STATE/ZIP <br /> ! <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> -❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION#i <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ISI <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 It PROPERTY LME R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) �n ! <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft `•1 i <br /> ! <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> _ ElFILTER BED WIDTH ft LENGTH ft DEPTH R <br /> V <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R \ <br /> ❑ MOUNDED WIDTH _ ft LENGTH ft DEPTH ft C i <br /> i• <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LME ft I <br /> ❑ SUMPS WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WLLL R FOUNDATION R PROPERTY LINE R \ j <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> �{ I <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R -N <br /> ❑ SEEPAGE PITS NUMBER WmTR ft DEPTH <br /> - DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME R <br /> ' 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY I <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. 4 �C <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLE'A1'SE CALL(209)953-7697 y c I I <br /> SIGNED TITLE - i-c• - DATE 1 T <br /> i <br /> I <br /> { —— I <br /> N O O tN <br /> DEPARTMENT USE ONLY HEALTH DEPARTMENT 4 i <br /> Application Accepted By 7`x-7 t Date /y�l�US Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 FR Pit/Sump Soil Character: i <br /> COMMENTS <br /> i PE SC Received �Checldi/ Amount Permit/ { <br /> Invoice# Permit ID# <br /> Code INFO B Cash Remitted Date Service Re oast# <br /> �rz.z2 S`JS 1 %0��. vinS�J• I�� li / (CIL ! j -� 3 <br /> I ' <br /> i <br /> j <br /> 42.02-001 ONSITE WASTEWATER PERMIT � <br /> 12/12/2003 <br />