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ONSITE WA ,EWATER TREATMENT SY` EM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT*6EPARTMENT 304 E WEB�VE -3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)95/3,-7697 FoR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS b Ga,k �� <br /> C` •_ <br /> IrTY/ZIP ^y <br /> CROSSSTREET APN V�/ ! Vl — PARCEL SIZE T <br /> OWNER NAME Wes tg-tl / VY5-k-,e� 5 <br /> POV <br /> OWNER ADDRESS /D6Ls5L <br /> � <br /> �' �12 <br /> CITY/STATE/ZIP �Q�! -75-49�3Z-- <br /> CONTRACTOR lit y��/��ffj�` rf- <br /> J'� ,. �'/ C� .yam PHONE <br /> J �i/y�- <br /> CONTRACTOR ADDRESS ,i' 7— ) W , ��- .iT.�` CITY/STATE/ZIP �L�LI v i �� <br /> LICENSE ❑C-42 ❑C-36 . OTHER NUMBER [ <br /> EXPIRATEON DATE +� <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> FERC TEST(S) NUMBER 2. LAND USE APPLICATION# ' <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LINE t <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft d <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH }t <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH }j <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 WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft 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 ORDINANCES, <br /> JHRADVANCE <br /> E LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> M U4IUM 24 NOTICE RED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> SIGNED TITLE ®LIl�/! DATE Aq,�, <br /> r <br /> 5` <br /> s <br /> i Q <br /> �7 J <br /> Sq <br /> fR NM N <br /> " T W r <br /> I <br /> L <br /> DEPARTMENT SE(}. Y <br /> Application Accept y at Area Employee ID# <br /> Final Inspection B Date r ❑ SPECIAL PERMIT-Approved by <br /> Character Soil to Depth of3 Ft: Pit/Sump Soil Character: <br /> C0MMEI� �� _ �/ <br /> 12 <br /> PE Sc Received Check#/ Amount Date Permits Invoice# Permit ID# <br /> Code INFO 13 Cash Remitted Service Re nest# <br /> 42-01-IRII <br /> 12a/Q2 ONSITE WASTEWATER PERMIT <br />