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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 IYEAR FROM DATE ISSUED <br /> CITY/ZIP G <br /> JOB ADDRESS /-1. b 2 o SIU 1►� w ,r <br /> CROSS STREET' A\ J AP <br /> 6 ' PARCEL SIZE <br /> - <br /> O � HONE <br /> OWNER NAME V y <br /> GY O <br /> Li 2 SnS (� CITY/STATFJZIP�`������C.C." <br /> OWNER ADDRESS C C` <br /> CONTRACTOR Se. PHONE <br /> CONTRACTOR ADDRESS CITY/STATFIZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinate$ X Y <br /> ❑ PERC TEST # BUILDING PERMIT#_. LAND USE APPLICATION# <br /> TYPE OF WORK: (3 NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT <br /> DESTRUCTION 0 C-Q -,—A A' <br /> INSTALLATION WILL SERVE: RESIDENCE LI COMMERCIAL ❑ OTHER <br /> � NUMBER OF LIVING UNITS: D /L NUMBEROFBEDROOMS: NUMBER OF EMPLOYEES: <br /> U/SEPTIC TANK TYPE/MFG P-J, CO n c,r.le T CAPACITY gal #OF COMPARTMENTS 2- <br /> 0 <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL 100' t ft FOUNDATION I d R PROPERTY LINE 10 ft <br /> ❑ LIFT STATION SIZE TYPEOFPUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) —� <br /> S <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES it N <br /> �� DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH Z_ ft LENGTH3 <br /> ? O ft DEPTH �/ -7-1 ft <br /> Lk- � <br /> DISTANCE.TO NEAREST WELL 160 'I` R FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE _ 0 <br /> ❑ SUMPS WIDTH fl LENGTH ft DEPTH fl <br /> DISTANCE.TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH H DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 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 OUR DVANC' OTICE,REQUIRED FOR INSPECTIONS-PLEASE.CALL(209)953-7697 <br /> SIGNED - TITLE Ow f t-e _ DATE 1-2-—O� <br /> 77777-777TT <br /> E <br /> 0 <br /> f N <br /> FFA I <br /> O 1 <br /> I <br /> 1 <br /> j�'` <br /> I DEPARTMENT l NE(NLY r <br /> Application Accepted-By gn Date- <�)I,� Area Employee IDN---�-t'G411 <br /> LS� . <br /> Final Inspection By Date 12,;* <br /> 4J ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PIUSump Soil Character: <br /> CO��MwwMENTS 0Q L G i G FAC--C U ZO <br /> #v� *. <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit 1D# <br /> Code INFO B ash Remitted Service Request# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> )/'' 12122f2003 <br />