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9 <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE - 3`1 FL- STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT11 CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />� l. �V•�_ CITV/ZIP - <br />J08ADDRESS SQ DAJ �oQ <br />-`` <br />tO <br />' <br />CROSS STREET a ,� �/L\\ OL 13-► C� 'PARCEL SIZE <br />` <br />OWNER NAME Tib ti•---�^ a1\!i�'�T�i h� PHON <br />OWNER ADDRESS �Q._\ �Y `�C`(� 1 q CITY/STATFJZIP <br />CONTRACTOR 0 -.v Cie PHONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE ❑ C-42 ❑ C-36 OTHER NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: % l7 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ FERC TEST # J� BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEw INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br />❑ REPLACEMENT ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: SI RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS:_____L_ NUMBER OF BEDROOMS: 1,3 NUMBEROFEMPLOYEES: <br />�I SEPTICTANK TYPE/MFG P4AA L CAPACITY 1 Zoo gal #OFCOMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />❑ PKG TX PLANT DISTANCE TO NEAREST: WELL L r r ft FOUNDATION C: ft PROPERTY LINE 157- <br />5 <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />13 <br />❑ LEACH LINES 0 LEACH ING CHAMBERS Eocttl,zee 36 #OFLINES .3 LENGTH OF LINES X001 ft <br />DISTANCE TO NEAREST WELL i(� ft FOUNDATION �C ft PROPERTY LINE 'S R <br />❑ FILTER BED WIDTH ft LENGTH ft DEPTH R <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br />❑ SUMPS WIDTH ft LENGTH ti DEPTH ft <br />DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft <br />❑ SEEPAGE PITS NUMBER WIDTH ft DEPFH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE. CALL (209) 953-7697 <br />SIGNED L\y �i �'--- -_ _ TITLE m k 1. �\ •C-� DATE 1 `'�I •. <br />kA <br />I <br />A UI uquil <br />N <br />9 <br />y i 2" 134 Cth Lb,&,— S P <br />5 <br />l/ <br />La c <br />DEPARTMENTUSE <br />\'LY <br />Application Accepted By, - _ _ Date - 7 r-1— Area Employee ID# 4 <br />J <br />Final Inspection By ate ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to De 1 of 3 F; PiU ump Soil Character: <br />COMMENTS 4104.0 ZO' <br />PE Sc Received Chec Amount Permit/ <br />Date Invoice # Permit ID# <br />Code INFO B Cash Remitted Service, Request III <br />7:* <br />42-02-001 ONSITE WASTEWATER PERMIT <br />12/22/2003 <br />9 <br />