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ONSITE WAST�1ATER TREATMENT SYSTI�'PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAAAeMENT 304 E WEBER AVE C"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS ,L,,` L CITY/ZIP 1 IS (-0(0 DL m <br /> CROSS STREETr V V�1 Mn VI. APN 22 0p- I1IO-�, ) PARCEL SIZE .i�ApC <! D <br /> 0 <br /> OWNER NAME Jo`nr Vr',el,Y1% Col`1 -129S <br /> ( CA /JPHONE n/� 1 y <br /> OWNERADDRESS I14o3 W. 1-51p7n ��. CITY/STATE/ZIP R01,w) '15350 <br /> CONTRACTOR Nhk PHONE ID -�� I <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER ERPIRATION DATE <br /> WATER TABLE DEPTH: I1 GEOGRAPHICAL INFORMATION: Coordinates X V <br /> Ef PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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 TYPEIMFG CAPACITY gal #OF COMPARTMENTS A I <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LME it I� <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME R <br /> 1 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 /> MINIMU 24 HOUR ADVANCE NOTICE REQ [RED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE l`_ a DATE1\1 ENP <br /> u•m <br /> PA <br /> Sr 8 V <br /> -12 <br /> S 0 0 N <br /> p THDEAFTrvENT <br /> �I <br /> 41! T-^P�Y 'ECJ' `., ..,. �• <br /> ..� -nssr aleoBaoAD AIP <br /> oy <br /> DEPARTMENT E ONLY c�6//c•� q <br /> Application Accepted By — Date S Q,$ Area Employee ID# TL�� /G <br /> / <br /> Final Inspection By Date - 11SPECIAL PERMIT-Approved by <br /> Character of Soil to De th of 3 Ft: Pit/ ump Soil Character: <br /> COMMENTS <br /> PE Sc Received heck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> 42_-z 5z1 3 �3 c�0 \\ /c•cfJ <br /> 42-02-001 ONSITE WASTEWATER PERUIT <br /> 12222DO3 <br />