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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-3"FL-STOCKTON CA 45202-(209)468.3420 <br /> NON-REFUNDA ERMIT CALL 09 953-]597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> / ) }ACITY/ZIP y <br /> CROSS STREET © - Tv I PiG.^ APN <br /> 4 (, PARCEL$IZE L $ <br /> OWNER NAME <br /> OWNER ADDRESS <br /> CITY/STATEI%IP <br /> CONTRAC,7'GR - 1.' l,�,) j C'�� <br /> _ PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/LIP <br /> LICENSE C-42 O G36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION; Coordinates X <br /> ❑ FERC TEST y <br /> # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION' REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT DE$TRE)M. ON C)L-4 7-A-NIC. <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NCMBER OF BEDROOMS: i BER OF EMPLOYEES: <br /> f <br /> �C SEPTIC TANK <br /> GREASE TRAP TYPElMrG TYPE/MJ CAPAC Y----��lL #OF COMPARTMENTS. <br /> ❑ CAPA Tv gal #of COMPARTMENTS <br /> ❑ PKG TX PLANT DLSTANCETO NEAREST. WELL R' FOLNDATI R PROPERTY LINE��� <br /> R <br /> ❑ <br /> LIFTSTATION StzE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R u <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft -1 <br /> L) FILTER BED WIDTH_ ft LENGTH R DEPTH R <br /> 13 MOUNDED <br /> TO NEAREST WELL,._ ft FOUNDATION _R PROPERTY LINE it .� <br /> MOUNDED WinTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION_ R PROPERTY LINE, ft <br /> LI SUMPS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATIONR PROPERTY LINE ft <br /> CI DISPOSAL PONDS WIDTH Lift LR DEPTH R <br /> DiS1'ANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> L) SEEPAGE PITS NUMBER WIDTH R DEPTH <br /> ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORN WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> ftMMINI IIM <br /> W <br /> C N( I-REQUIRED FOR tS-PL� .L('_091953-?h97 <br /> SIGNED 1.J\ <br /> 'I'ITL, DATE <br /> OI U <br /> N R <br /> e� <br /> r <br /> DEPARTMENT US ONLY' -- <br /> Application Accepted By Date_ (' L+ <br /> Area Employee ItNx <br /> Final Inspection By Date ❑ SPECIAL PERMIT <br /> Approved by <br /> Character of$uilloDept f3Ft: Pit/ mpSoilCharai <br /> COIHIVl$�l1'$ -_' <br /> PE SC Received Check#/ Amount Pei mit/ <br /> Code INFO 6 Cash Remitted Date , Service Re nest# Invoice# Permit f1)# <br /> 42-02-001 <br /> 12/22(2003 ONSITE'WASTEWATER PERMIT <br />