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�o SCAN,' -"-2. <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"D FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(2209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �� C ADA A-,f l l©C�t©A � CITY/ZIP /�[D� L <br /> h <br /> CROSS STREET 0 <br /> APN 3 6 510 7 PARCEL SIZE 5Lv <br /> OWNER NAME i PHONE L t( C)w H q y <br /> OWNER ADDRESS P J Rr)/l � <br /> - ) k> V 1 o C ro viC ed CITY/STATE/ZIP )� b <br /> CONTRACTOR "' PHO I <br /> v <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# 04 0 LAND USE APPLICATION# <br /> TYPE OF WORK: Pk NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> NT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: x NUMBER OF BEDROOMS: ��`` NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG � CAPACITY ?.,(�y gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY �\ gal #OF COMPARTMENTS <br /> L3PKG TX PLANT DISTANCE TO NEAREST: WELL _ ft FOUNDATION �/ ft PROPERTY LINE 3 0 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES O ft <br /> DISTANCE TO NEAREST WELL_IAC\ _ft FOUNDATION R PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <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 /> SEEPAGE PITS NUMBER 3 WIDTH . ft DEPTH Z ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 'L 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 /> MINIMU24 HOUR ADVA E TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED_ /1f' �_ C '� TITLE DATE <br /> r, <br /> hAtY { <br /> MIA IF <br /> S M NT L <br /> E T D <br /> 11 -rim I <br /> DEPARTMENT USE NL <br /> Application Accepted B Date v Area Employee ID# Q <br /> Final Inspection B Date [3 SPECIAL PERMIT-Approved by �` 9 <br /> P Y <br /> Character of Soil to Dept of 3 Ft: it/Sump oil Character: <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> W/O -,20 0 3'3� <br /> 42-02-001 ONSITE WASTEWATER PER% <br /> 12/22/20#3 <br />