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ONSITE WA* EWATER TREATMENT SYP �M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E W EBE09KE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(2,0119)953-7697 FOR INSPECTIONS EXPIRESr�I YEAR FROMDATEISSUED <br /> JOB ADDRESS I�fr[� V ( �1 I S /`F'��' CITY/ZIP <br /> �1 <br /> CROSS STREET to -21(D-32- PARCEL SIZE 11 p <br /> O <br /> - ) 5l"3 -/L� <br /> OWNER NAME �t .(,%'Z/J( � (c2.r' �./ I PHONE �2 <br /> L� � <br /> OWNERADDRESS - r / V - m K `O J CITY/STATE/ZIP S �O C_ �'✓� Ci/ S2�' <br /> CONTRACTOR PHONE 3 2"r O S <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# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDIT ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> IO <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 /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R AT ION R PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OFiP <br /> / ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELLE UNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH H,1 (TH ft DEPTH ft <br /> DISTANCE TO NEAREST f/lfFY� ft FOUNDATION ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH it _J) <br /> DISTANCE TO NEAREST WELL ON ft PROPERTY LME ft Q <br /> ❑ SUMPS WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELT //� ft FOUNDATION it PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft I LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL H FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft R� <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE it ,-\- <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY -F <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MI ' U 24 UR 'ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> 1 <br /> P E <br /> RE EIVE <br /> R <br /> s <br /> T DPAI T ET <br /> I <br /> f <br /> DEPARTMENT USONLY <br /> Application Accepted By Date Area Employee ID# Y 99 <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS /1 LOST JJ i=,r 7W0 ce--L[ /�0 Y�(`����lj( ,a , 12kE =AU • �,tl�jf <br /> . I �r <br /> co J i�� 7c,as/ ii/r.3J- om J <br /> PE SC Received Amount Date Permit/ Invoice# Permi[ID# <br /> Code INFO B Cash Remitted Service Request# <br /> 42-:2.1 rnsoa. 15Dlot).a-L) L2-0 <br /> 42-D2-DB1144 S4 ��guf'�rL���-3/�d/t(oj�/J 1�� �� ONSITE WASTEWATER PERMIT <br /> 12/2212003 <br />