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10 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"FL-STOCKTON CA 95262 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-776997 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7Ii n S'Tz'C 64 CITY/ZIP <br /> CROSS STREET _.0t;rk.c M r{rr J APN 2-5-J �G! PARCEL SIZE L J o <br /> OWNER NAME � 1 n rt ! 110 _ PHONE M!•, <br /> OWNER ADDRESS .7��` CITYISTATEIZIP <br /> CONTRACTOR f( r C PHONE. S <br /> CONTRACTOR ADDRESS 1s k CrrY/STATE/ <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE I� <br /> WATER TABLE:DEPTH: 12 GEOGRAPHICAL INFORMATION: Coordinates X J Y ` <br /> L ❑ PERC TEST # LDING PERMIT t# LAND USE APPLICATION <br /> BUI #S_ 1 <br /> TYPE OF WORK: ❑ NEW INSTALLATION tr REPAIR/ADDITION ❑ ENCI.NEER DESICNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: 0"RESIDENCE ❑ COMMERCIAL <br /> � ❑ OTHER <br /> t1 <br /> NUMBER OF LIVING UNITS' NUMBER OF BEDROOMS' NUMBER OFEmpLOYEES: _ <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DIS-TANCETO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION ..SLzf TYPE OF PUMP 1�7' SAND SEPARATOR(ENCLOSED SYSTEM) <br /> W C LEACH LINES LEACHING CHAMBERS �-'� OFINES - LENGTH OF LLNES <br /> DISTANCETO NEAREST WELL 4,�--ftFOUNDATI ft PROPERTY LINE �C�/ ft <br /> ❑ FILTER BED WIDTH tl LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE h <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 ft FOUNDATION ft PROPERTY LME ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft A <br /> ❑ SEEPAGE PITS NUMBER WIDrH ft DEPTH ftJ <br /> DISTANCETONEAREST WELL ft FOUNDATION It PROPERTY LINE ft <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. <br /> J>t I,N(I MUM 24 HOUR ADVANCE NOTICE RF,QU IRE)FOR INSPECUIONS-,LPLL-FASE CALL(209)953-7097 <br /> SIGNED 'Lt^" .+ TITLE t -r1 Kr�t `�� � DATE t3 <br /> ,n <br /> L <br /> z <br /> i <br /> E kT <br /> -- - DEPAARTMENTIISE N V (� <br /> Application Accepted By aie Arca Employee IDN�6/! <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> CharActer of Soil to De of 3 FC P' Sump Soil Character. <br /> COMMENTS P � <br /> PE SC Received Chec{Cff. Amount Date Permit! Invoice# Permit IDN <br /> Code INFO 6 Cash Remitted Service R uest# <br /> 4242.001 ONSITE WASTEWATER PERMIT <br /> 12(.2/2003 <br />