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/ ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"0 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 Y R 1NSPECTIO.NS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �7A�L/�I /'SeA PJ0 4-' CITY/ZIP �-OC� 9 �(i 0 yi <br /> CROSS STREET 1t-}-F�I�f�S 1/�Q s� APN O/2/S/Q j& PARCEL SIZE__-�9 -3 0 <br /> !-T"(.9 Cad A <br /> OWNER NAME D11}fWl -� PHONE f� <br /> OWNER ADDRESS % 1 L �'/��(/)� `jam CITY/STATE/ZIPZA)Je-4 <br /> CONTRACTOR <br /> Prwne —�•( p <br /> CONTRACTOR ADDRESS �+ ��/�ll ,-- aV - CITY/STATEIZAP �' 3 <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE i p <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: fi NEW INSTALLATION ❑ -REPAIR/A DDITION LJENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: Ca RESIDENCE ❑ COMMERCIAL D OTHER <br /> ,6 NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS: G NUMBER OF EMPLOYEES: <br /> iI SEPTIC TANK TYPF/MFG i�l✓L/C•} Gy CAPACITY fC��� gal #OF COMPARTMENTS -Z <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL 1,VL2 ft FOUNDATION /0 R PROPERTY LINE -O�Z� ft <br /> C3 LIFT STATION SIZE TYPE OF PUMP 13 SAND OIL SEPARATOR(ENCLOSEDSYSTEM) <br /> m LEACH LINES ❑ LEACHING CHAMBERS #OF LINES_ 2— LENGTH OF LINES <110 it •� <br /> DISTANCE TO NEAREST WELL FOUNDATION ZO A PROPERTY LINE _�n C3'r ft <br /> ❑ FILTER BED WIDTH fl LENGTH fl DEPTH fl �JNI <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE fl <br /> ❑ MOUNDED WIDTH Il LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LME it <br /> ❑ SUMPS WIDTH fl LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE it <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH fl DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ft <br /> l� SEEPAGE PITS NUMBER_ _WWTH 2 '/ B DEPTH <br /> —2".7 ' —ft <br /> DISTANCE TO NEAREST WELL /•SU It FOUNDATION ft PROPERTY UNE ._S'oO • R <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 /> INIMUM 2 HOUR ADVANCE NO]ICE REQUIRED FOR IVSPECPIONS-PLEASE CALL(209)953.7697 <br /> SIGNED TITLE_ rLJ'f•�4 tJ� i�— <br /> DATE Zts p� <br /> Id <br /> ljo <br /> 4 <br /> N G L <br /> PA T <br /> r <br /> DEPARTMENT SE O* V•y <br /> Application Ace - y Date Zy al) Area '2 111 :?, EmploycelD# <br /> Final lnspec on By Date ❑ SPECIALL_)P�ERRN IT-Approv b <br /> Character of,o to Depth of3 Ft: Pit/Sump Soli Character: <br /> COMMENTS <br /> PE Sc Received heck#/ Amount Date Permit/ <br /> Code INFO B Remitted Service Re uest# Invoice Pe it <br /> 21 9s 5 o Dov 3 w <br /> 42-t/2-001 <br />