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�I <br /> 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 roR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS �i>- �i !- t� CITY121P Iv. ') it <br /> l CROSS STREET '�'�i Yl ty; APN -G J - -�J�` 'U'S PARCEL SIZE -'y '!L_ e <br /> [ 1` r� A <br /> 1 OWNER NAME t i-1 3 YT PHONE <br /> OWNER ADDRESS CITYISTATFIZIP AA,,{C Cil <br /> Y ! '- S-I <br /> CONTRACTOR -1 �...I C�-1 PHONE <br /> I` CONTRACTOR ADDRESS } _{'�jl,I 'IL CITYISTATFIZIP �•�f r <br /> LICENSE ❑C 42 ❑C-36 OTHER NUMBER ExriRATION DATE <br /> ! q WATER TABLE DEPTH: ft GEOORAPHICALINFORMATION: Coordinates X Y <br /> { _ ❑ PERC TEST BUILDING PERMIT# LAND USE APPLICATION# OP-'""4 - C) <br /> { 1 TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNEWALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE O COMMERCIAL ❑ OTHER <br /> NDMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLDYEES: <br /> I ❑ SEPTIC TANK TYPE/MFG CAPACITY gal N OF COMPARTMENTS <br /> © GREASETRAP TYPUNIM CAPACITY gal #OFCOMPARTMENTS <br /> G <br /> 0 PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION R PROPERTY LINE R �.. <br /> 1 <br /> ❑ LIFT STATION SIZE TYPEOFPOMP Q SAND OIL SEPARATOR(ENCLOSED SYSTEM) `3 <br /> �f ❑ LEACH LINES 4 LEACHING CHAMBERS #OF LINES LENGTH OF LINES it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL it FOUNDATION R PROPERTY LINE ft t <br /> P <br /> Ll MOUNDED WIDTH t LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> !t C3 sumps WIDTH ft LENGTH ft DEPTH R <br /> I i <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft �- <br /> { II ❑ DISPOSAL PONDS WIDTH fl LENGTH R DEPTH R v <br /> DISTANCE TO NEARF.Sr WELL ft FOLNDATION fl PROPERTY LINE ft _ <br /> ` ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> s -• <br /> DISTANCETO NEAREST WELL ft FOUNDATION R 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 /> sl <br /> ` MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ,'J�' !f es%> .t _ TITLE -/ I /r=< DATE <br /> I <br /> :! <br /> 1 <br /> 11.777-7. <br /> • -_-...--- -� ; / <br /> DEPARTMENT US46NL r3�s <br /> s••�., Application Accepted By �� �7` Date 1'9 1 )-1; Arm Employee ID# / <br /> F <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by 5 / <br /> ' Character oCSoil to Depth of 3 Ft: Pit/Sump Sail Character: <br /> COMMENTS <br /> I <br /> PE SC ReceN r Che Amount PerlmU <br /> Date lnvokce# Permit IDd! <br /> Code )NPD Cash Remitted Service <br /> R atst# <br /> I 42-02-ppl ONSITE WASTEWATER PERMIT <br /> 4 <br /> 12127)2003 <br />