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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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �/y'9/ F Ili- /e','naly ��lwe CITY/zIP LSD ! A <br /> OCROSSSTREET 11 ! -z APN v�-S' —�= PARCEL SIZE <br /> 053-zu —c 6 <br /> OWNER NAME �� r TI PHONE 34 <br /> OWNER ADDRESS T�-G ��n! i'1r¢ CITY/STATE/ZIP 11fnej1-t� <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ EXPIRATION DATE G <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE L1COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: 3 NUMBER oFEMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG. &z L4't 5' CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE_ TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> t�LEACH LINES ❑ LEACHING CHAMBERS #OF LrNES�_ LENGTH OF LINES y0 ft <br /> DISTANCE TO NEAREST WELL /SO R FOUNDATION R PROPERTY LINE T_S-o t ft I;' <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LME ft <br /> ❑ MOUNDED WIorH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ SUMP$ WIDTH ft LENGTH R DEPTH ft m <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> 1!r-SEEPAGE PITS NUMBER WIDTH ft DEPTH ZS ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION CO _ft PROPERTY LINE Scl R <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPF.CTIONS-//PLEASE CALL(209053-707 <br /> SIGNED TITLE /SZ/JL DATE S�LIZ5 A X— <br /> w' <br /> S , <br /> 77 8 <br /> OL N <br /> 10 <br /> T <br /> .L <br /> V <br /> DEPARTMENT U E0 LY TMENT <br /> HEALTH DEPAR <br /> Application Accepted By ��`/�— Date S F G'S Area Employee ID# L�(c Q J <br /> Final Inspection By Date ❑ SPEC I�.P MIT- roved by <br /> Character of SoU to Depth of FC PiUSum\\p Soil Character: <br /> COMMENTS AJ�w yr p F QEc.a�.� PA V i FW <br /> at <br /> PE S Received / Amount Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted to Service R uest#/- <br /> 2.i0 115 !o <br /> 42/22-001 -s 7j�1 G�/.r2� �G.Y �„t✓!L""`-' c RPE <br /> RMIT <br /> 12/222003 ��/ <br />