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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 M T CALL 2 953-7697 FO INSPECTIONS foNPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS O / CITY/!'ZIIP� <br /> CROSSSTREET Ael AIN PARCFLSIZE <br /> 0 <br /> OWNER NAME tA <br /> PHONE 3319 <br /> OWNER ADDRESS �-+ Gr'ID .S'O.-V CITY/STATE/ZIPAd42!2 <br /> CONTRACTOR 5 N PHONE 3IOeL -' ✓{ <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP 14L, <br /> LICENSE 51t42 ❑C-36 OTHER NUMBER EXPIRATION DATE og <br /> D \ <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: f NEW INSTALLATION Cl REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUM�BlE,R rO1F BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG,_ �J�IL��CAPACITY J SJ gal #OFCOMPARTMENTS p _ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY /1 gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETo NEAREST: WELL ft FOUNDATION �V T ft PROPERTY LINE(e," ft <br /> ❑ LIFT STATION SIZE TYPE UMP D OI SEPARATOR(ENCLOSED SYSTEM) <br /> J�( LEACH LINES LEACHING CHAMBERS #OF LINES�_ LENGTH OF LINES T� ft <br /> DISTANCE TO NEAREST WELL —ft FOUNDATION� ft PROPERTY LINE �O ft <br /> ❑ FILTER BED WIDTH ft LENGTH fl DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE.TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH it DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> SEEPAGE PITS NUMBER WIDTH ) ft DEPTH .2.5L-- R <br /> DISTANCE TON ARFST WF.I,1. eft FOUNDATION �) ft PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 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 /> ADVANCE NOTICE'REQUIRED FOR INSPE IONS-PLEASE CALL(209)953-7697 <br /> SIGNED S'p"TITLE DATE -!57a <br /> s' <br /> r5 <br /> H E AwM <br /> a <br /> 44N <br /> DEPARTMENTN�E(Y.�LY <br /> Application Accept Date!J?�- Area Employee ID# <br /> Final Inspection y _ - -'� ❑�1 Date ✓.,).: ❑ SPECIAL PERMIT-Approvedby _ <br /> Character of Soil to pth of 3 t: - Pit/5ump Soil Character: <br /> COMMENTS i-sJ%afb. <br /> /':Y,:�,..oma ��,.. ..{� �'.� -,v'i;.. ✓ - Ly _ --�i/'v , <br /> PE SC Received C eck#/ Amount Permit/ <br /> Code INFO By Remitted Date Service Request# nVol"# �, Permit, <br /> 5. <br /> 42-02-001 �- ONSITE WASTEWATER PERMIT <br /> 12/2212003 <br />