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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 I YEAR FROM DATE ISSUED <br /> L VC�^ P <br /> JOB ADDRESS CITY/LIP a <br /> I �'/7' D <br /> CROSS STREET APSPARCELSIZE"i11(�ff--1111YYY�'`'Y���"""''�� I <br /> O <br /> OWNER NAME 1 _ <br /> PHONE— <br /> OWNER <br /> ^J <br /> 717 /�i—+ <br /> OWNER ADDRESS Irl ITY/St'ATEIZIP / -tom/ <br /> CONTRACTOR L PHONE �Q r <br /> CONTRACTOR ADDRESS CRY/STATE/ZIP <br /> I <br /> LICENSE C-42 ❑C-36 OTHER NUMBER E TIRATION DATE <br /> WATERTABLEDEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> O PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: )r NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL, ❑ OTHER <br /> NUMBER OF LIVING UNITS: ,,NI UMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> 17p SEPTIC TANK TYPE/MFG A,- CAPACITY / O.C� gal #OF COMPARTMENTS_ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> r <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL "LO— ft FOUNDATION ft PROPERTY LME O R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 3 LEACH LINES ❑ LEACHING CHAMBERS #OF LINES� LENGTH OF LINES ft <br /> / ' �fD ft <br /> DISTANCE To NEAREST WELL R FOUNDATION � ft PROPERTY LME <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH tl LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL��,'T_7� lFOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER � a'WIDTH Yd"I ft DEPTH r ft <br /> ft <br /> DISTANCE TO NEAREST WELL ZOO* R FOUNDATION /4000 It PROPERTY LINE Oka <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 2_4 HQI�R AU�NCE VO'TICF;REQUIRED FOR INSPECTIONS-/PLEASE CALI,(2(19)453-7697 <br /> SIGNED TITLE�/1��1Y1//�Y DATE O <br /> v � <br /> i <br /> i <br /> ITP S <br /> EN 4i N E T <br /> M <br /> TTT <br /> Application A ted Date O` Area Employee ID# <br /> Final Inspection ����(/ Date �a�a'�i/57 ❑ SPECIAL PERMIT-Approved by / <br /> Character of Soil to Dept of 3 Ft: Pit/Sump Soil Character. �y <br /> COMMENTS <br /> PE SC Received ChecW/ Amount Date Permit! e# Permit ID# <br /> Code INFO BV Cash Remitted Service Regues <br /> ONSITE WASTEWATER PERMIT <br /> 42-02-001 <br /> 12/13/2003 <br />