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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> �IN-JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"O FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT �/ •CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DQATE ISSUED <br /> JOB ADDRESS -T >Z A) (I '' 4 F CITY/ZIP S 7 t-jG-z-m e L / <br /> � <br /> CROSS STREET C�of��(:Y LI G t S APN PARCEL SIZE I, a AC p <br /> OWNER NAME 1 1'�- <br /> ( �� � � PHONE <br /> OWNER ADDRESS % `��v" A ,l` CITY/STATE/ZIP SA•— <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <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 /> .A REPLACEMENT DESTRUCTION OC-4 -Tib-NV— <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 / NUMBER OF EMPLOYEES: ^� <br /> SEPTIC TANK TYPE/MFG -7-6 J 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 LME ft <br /> �❑[ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I LEACH LINES ❑ LEACHING CHAMBERS #of LINES LENGTH OF LINES 5 ft <br /> / DISTANCE TO NEAREST WELL 50 + ft FOUNDATION ft PROPERTY LINE ft <br /> I FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> C3` MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R G <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft 1� <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 ft 'FOUNDATION ft PROPERTY LINE ft <br /> J6L SEEPAGE PITS NUMBER � WIDTH ~F ft DEPTH 25 ft s� <br /> / DISTANCE TO NEAREST WELL )00 -4- ft FOUNDATION ft PROPERTY LINE ft <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 /> 6 <br /> MINIMUM 24 H R ADVANCE NOTICE REQUIRED FOR INSPECTION'S R-P�L-EASEICCA`LL209)953-7697 / <br /> SIGNED TITLE V� `' �'� DATE <br /> f • <br /> 1-3 <br /> c <br /> yJ o I <br /> �k .� <br /> .01 <br /> 1 <br /> Kota <br /> c <br /> EPARTMENT USE)ONLY <br /> Application Accepted By -' Date /0/(070!g— Area Employee ID# S� 1 <br /> Final Inspection B Date <br /> p y ��� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dep of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS 0t-41 L--6T � f Q..1.0 Cr 2 5.7�,.dGr���7 <br /> ill ltit3�zr,Cb�J > �i ..Se*e Ty ACAV S T. Ae,:5� zd Z_4'-6 ' kjCCe ��%�= <br /> �CJLG�Z'U LC,is .ar �Ty% JGjIL Cs!`7</d ° 59C a C.J"'G S LS <br /> PE SC Received C ec Amount Date Permit/ Invoice# Permit ID# ` <br /> Code INFO B Cash Remitted Service Request# <br /> �Z.IQ f!S 30,oc) Q <br /> 42-02-001 <br /> ��t/ s 'S Gist uc za /z7 <br /> 12/22/2003�� �`'� GD j�(9�(/y/� G/ 'S'LQ.� IPER IT <br /> 6/� J <br />