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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3M0 FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS i D{ �- \•�t! �; C CITY/ZIP i`)(6!n t� ,� C I'• G r <br /> CROSS STREET + �' (`-'-\ APN ``- -� "� �-t c�Z- PARCEL SIZE 6 ' <br /> OWNER NAME y1\ \�t. L ?'-�` J CC- PHONE <br /> OWNER ADDRESS <br /> !1- �. ' S 1�. .I). i`V_` �1 it CITY/STATE/ZIP ' -� ,r 1.•I <br /> CONTRACTOR ( l`�4 \ / PHONE ' <br /> CONTRACTOR ADDRESS I( L `I• s t - I, .r•_. S CITY/STATE/ZIP I, <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑' PERC TEST # ( BUILDING PERMIT# LAND USE APPLICATION# 91 - I r <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: <br /> I <br /> ! ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG � CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC 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 LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> ' I DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft 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 R FOUNDATION ft PROPERTY LINE ft <br /> f ❑ 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 It <br /> iDISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> I HEREBY CERTIFY THAT 1 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED I' t ,� t' l i,' TITLE DATE i ! <br /> ..__._...._. <br /> E \I Y I \ <br /> OA <br /> i <br /> •I � �...__a eu � .....�.�...w.. ...i ��� A ... <br /> N f <br /> t <br /> _ 1 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By _•� "— Date U L,l G 7 Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> I <br /> PE SC Received _Check#/_ Amount Permit/ <br /> Code INFO �:B Cash <br /> � Remi a Date Service Request# Invoice# Permit ID# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> i 12122/2003 _}- <br />