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r <br /> V <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3R°FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS `.EXPIRES I YEAR FROM DATE ISSUED <br /> a� JOB ADDRESS ✓' Y F N 5-li D. <br /> at t�l CITY/Zip �r+� ��G <br /> �"+�' APN""yn'I"4 -N V PARCELSIZE 3 <br /> CROSS STREET `I `IN �� {- -I q <br /> OWNERNAME V`.t ! N/�4-- �` Q �.. - PHONE I''I <br /> INS OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS 7N CITY/STATEIZIP 1�. v i_ A I I,Z <br /> Bass LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: fl GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> . PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDTTION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> r� ❑ 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 /> a- ❑ GREASE TRAP TYPE/MFO CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL fl FOUNDATION R PROPERTY LME ft <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 fl <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH fl <br /> DISTANCETONEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> V ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME fl <br /> ` ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WmTx ft DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTWV THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> bassORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> I MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ; —f^ �"�a- 4 TITLE �L.--.-� DATE - - <br /> I <br /> bw <br /> � � t <br /> - _ ' <br /> L <br /> ------ ---- <br /> Ion III <br /> V <br /> 11Af O <br /> A <br /> ------RTMENT SE <br /> Arca Employs ID# <br /> Application Accepted By - _it i�f ITL " I Date <br /> ❑ SPECIAL PERMIT-Approved by <br /> Final Inspection By Date <br /> Character of Soil to Depth of 3 FI: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received rC6ec Amount Date Perm1U Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> .lam•.. <br /> ONSITE WASTEWATER PERMif <br /> 4z-oz-ooI <br />