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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT CO <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3-FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS F j L r IP/'1 _ CITY/ZIP y <br /> CROSS STREET �4N 16410 / APN (�(J/—LQ D—46 6_ PARCEL SIZE <br /> OWNER NAME L�tr,r y -LFiH PHONE <br /> OWNERADDRESS CITY/STATE/ZIP 7 L <br /> CONTRACTOR a01622L PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 1111 C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: fl GEOGRAPHICAL INFORMATION: Coordinates X V <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ RF.PAIR/ADDITI ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NVMBEROF BEDROOMS: NUMBEROFEMPLoYEES: ( (' <br /> SEPTIC TANK TYPEIMFG CAPACITY 110,M Sal #OF COMPARTMENTS o^A <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETO NEAREST: WELL 1 ft FOUNDATION�_ ft PROPERTY LME �L Cy + It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINESLEACHING CHAMBERS #OF LINES _ LENGTH OF LINES ✓00 ft <br /> �f�1 <br /> DISTANCE TO NEAREST WELL / ft FOUNDATION H PROPERTY LINE OGCJ T ft <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft T <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION III PROPERTY LME A <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL, ft FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LME ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft 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 LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-IPLEASE CALL(209)953-7697 <br /> SIGNED TITLE�Gfi?AG/-•'fEsY DATE <br /> J <br /> L <br /> (2 IN o N <br /> EVIOIMI N KL <br /> DEPARTMENT US ONLY <br /> Applicatio Accept _ Date Area Employee ID# <br /> Final Ins tion By Date / ❑ SPECIAL PERMIT-Approved by <br /> Character o o to Depth 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> C— / .ff <br /> —I,-� <br /> PE SC Received C Amount Date Permit! Invoice# Permit IDN <br /> Code INFO B ash Remitted Ser vice R uest <br /> 2) tbr}3 o <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 1222.2003 <br />