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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR'I MENT 304 E WEBER AVE -3"FI.-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CAL 209 953-7697 FOR tSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS l CITY/ZIP I v <br /> CROSS STREET M��/C APN �W�` '� PARCEL SIZE a <br /> OWNER NAME ��G YV\ Z PHONE CX1 G-7- 12— 12 <br /> OWNER ADDRESS / A S CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# _ <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITIO. Ll ENGINEER DESIGNED/ALTERNATIVE <br /> Ll 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 TYPFIMFG 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 /> c <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #of LINES LENGTH OF LINES ft <br /> DISTANCE.TO NEAREST WELL. ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION Il PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION f1 PROPERTY LINE fl <br /> ❑ SUMPS WIDTH ft LENGTH 1`1 DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINF. ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTII ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEP I'H _ R <br /> DISTANCE TO NEAREST WELL fl FOUNDATION f1 PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAW'S AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE EQUIRED FOR INSPECTIONS�-PLEASE CALL 12091 953-7697 <br /> :•NSIGNED TITLE C.�fI�?11I`"' DATE. (� <br /> 1 <br /> Y <br /> Ir <br /> E <br /> C <br /> 1 <br /> DEPARTMENT tl 'E ON .Y/� <br /> Application Accepted B- Date Area Employee ID# <br /> i <br /> Final Inspection By Date 1 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: it/Sump Soil Character: <br /> COMMENTS cv 2-310 <br /> j `I O U �-r 1 GAO �� •% L � �,� <br /> Y JAy n S m K( L LyeY R i <br /> PE SC Received Xheew Amount Permit/ <br /> Code INFO B ash Remitted Date Service Request# Invoice# Permit IDN <br /> • <br /> 42-02.001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />