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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> w.N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)9✓153-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM D TE ISSUED <br /> �rB ADDRESS S A// CITY/ZIP <br /> CROSS STREET' <br /> LiTTT/ MAPN PARCEL SIZE <br /> NERNAME PHONE <br /> ER ADDRESS jeDDY CITY/STATE/ZIP 5AA /ZAI1/4 G/L <br /> " <br /> JCd <br /> J <br /> )NTRACFOR PHONE —"49Q.g "#.LNTRACLOR <br /> ADDRESS P. O. 'e —�I Ag CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> ATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X 01/— <br /> y/ Y <br /> PERC TEST(S) NUMBER LAND USE APPLICATION# v/�'2Y/ <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIWADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> r"STALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> LNUMBER OF LIVING UNITS: NUMBEROFBEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> r <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION it PROPERTY LINE it <br /> a. LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES it <br /> y DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> y MOUNDED WIDTH it LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SUMPS WIDTH R LENGTH ft DEPTH It s' / <br /> DISTANCE TO NEAREST WELL R FOUNDATION A PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH_ ft f <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> SEEPAGE PITS WIDTH R LENGTH ft DEPTH fl aA <br /> y DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE T <br /> tt r <br /> EREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLE SE CALL(209)953-7fi97 <br /> C. <br /> :NED L'I' iUG9 TITLE DATE <br /> &- N ' <br /> o- I J\ <br /> a ri I <br /> VfE ICNArED REMAW EER" F <br /> i 7 <br /> A J A t <br /> iW At H EP RT ET <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date -7 Dom' Area Employee ID# .5'V v <br /> Final Inspection By Date Z! Qs� ❑ SPECIAL PERMIT-Approved byc3 <br /> Character of Soil to Dept of Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE Sc Received heck# Amount Date Permit/ Invoice# PermitlD# <br /> Code INFO B ash Remitted Service Request# <br /> +?- 2-2- 5-21 � X07 9 3 c a o (�fJ G)�. <br /> 42-01-001 <br /> 12/2/02 ONSITE WASTEWATER PERMIT <br />