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�PM 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 /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED m <br /> JOB ADDRESS �! L1lNs1� _._ <br /> CITY/ZIP i- �• 'a <br /> -�' APN PARCELSIlE 6) n <br /> CROSS STREET <br /> �J/ r <br /> PHONE <br /> OWNER NAME <br /> CITY/STATE/ZIP <br /> OWNERADDRESS SY� e <br /> PHONE G`j-SOZ7 <br /> CONTRACTOR r G <br /> CONTRACTOR ADDRESS .� /S yD LANE <br /> CITY/STATE/ZIP 6z� <br /> i ci acl ExPIRAnON DArE Ssf3i.�'7 <br /> LICENSE -42 Cl C-36 OTHER NUtABE.. Y - ' — <br /> WATERTABLEDEPTU: ft GEOGRAPHICAL INFORMATION'. Coordinates X <br /> BUILDING PERMIT# LAND USE APPLICATION# <br /> ❑ PERC TEST # C1 ENGINEER DESIGNED/ALTERNATIVE <br /> TYPE OF WORK: ❑ NEW INSTALLATION SZ. REPAIR/ADDITION <br /> DESTRUCTION <br /> 411 REPLACEMENT <br /> ❑ <br /> INSTALLATION WILL SERVE: ®.RESIDENCE COMMERCIAL LJ OTHER <br /> NUMBER OF EMPLOYEES: <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 <br /> GJ CAPACITY l L OU gal #OF COMPARTMENTS <br /> �- SEPTICTANK TYPE/MFG f CAPACITY gal #OF COMPARTMENTS <br /> El GREASE TRAP TYPE/MFGft <br /> ft FOUNDATION ft PROPERTY LINE <br /> ❑ PKG TX PLANT DISTANCE To NEAREST: WELL ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LIFT STATION SITZ TYPEOFPUMP V� <br /> #OF LINES�-_ <br /> LENGTH OF LINES /(� ft <br /> LEACH LINES ®"LEACHING CHAMBERS �y ft PROPERTY LINE 6 ft <br /> DISTANCE TO NEAREST WELL 9*6 ft FOUNDATION ft <br /> ft LENGTH ft DEPTH <br /> ❑ FILTER BED WIDTH ft PROPERTY LINE -ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION <br /> ft DEPTH ft � <br /> ❑ MOUNDED WIDTH ft LENGTH ft <br /> ft FOUNDATION ft PROPERTY LINE�.— <br /> DISTANCETONEAREST WELL ft <br /> ft LENGTH ft DEPTH <br /> ❑ SUMPS wlDrx ft <br /> ft FOUNDATION ft PROPERTY LINE <br /> DISTANCE TO NEAREST WELL fl t <br /> R LENGTH ft DEPTH <br /> ❑ DISPOSAL PONDS WIDTH ft PROPERTY LINE ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION <br /> WIDTH ft DEPTH R n <br /> ❑ SEEPAGE PITS NUMBER $ PROPERTY LINE ft r <br /> DISTANCETONEAREST WELL ft FOUNDATION <br /> I 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. T <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE.CALL(209)953-7697 <br /> TITLE i _ '� DATE <br /> SIGNED <br /> I i <br /> OD <br /> �z <br /> E VI O M N <br /> r � <br /> - <br /> DEPARTMENT USE ONLY <br /> B' / <br /> _ I � Employee <br /> Application Accepted Date Area <br /> Final Inspection B <br /> L Date <br /> E3 SPECIAL PERMIT-Approved by <br /> Pit/Sump Soil Character: <br /> Character of Soil to Dep of 3 Ft: <br /> COMMENTS :,­0 /--L? jP <br /> PE SC Received C Amount Permit/ Invoice# Permit ID# <br /> Date Service R uest# <br /> Code INFO B Remitted <br /> 1' 1fV <br /> ONSITE WASTEWATER PERMIT <br /> 42-02-001 <br /> 12/22/2003 <br />