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o ONSITE WA, .;EWATER TREATMENT SY' EM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBEITAVE -3X0 FL-STOCKTON CA 95202 - (20 <br /> NON-REFUNDABLE ERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE <br /> JOB ADDRESS —LUI CITY/ <br /> ZIP <br /> CROSS STREET 14 APN N �3—(703 PARCEL SI D <br /> OWNER NAME WWA_ PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICALINFORMATION: Coordinates X Y' <br /> 0, PERC.GEST JE BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION 13 ENGINEER DESIGNED/ALTERNATIVE <br /> LI REPLACEMENT <br /> DESTRUCTIO [� <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL H FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES It <br /> DISTANCE TO NEAREST WELL H FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH R LENGTH It DEPTH it <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE. It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft' <br /> 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 /> MINIMUM 24 HOUR ADVA E NOT CE I?,EQUIRED FOyJRINSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGN DTLP.� DATE <br /> C <br /> U <br /> S JnNE <br /> 0 A <br /> DEPARTMENT SE LY <br /> Application Accepted Date Area Employee ID#� '{`1I <br /> Final Inspection B Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil[o D�lepft.r3 Pit/Sump Soil Character: <br /> Yit <br /> COMMENTS 01;�WV 2- rAIA ' plp_IA14 T /l6 FO- /_--'�4� 7 mc" J/{ e5w) <br /> C7,5-6 <br /> PE SC Received Check#/ Amount Date PermiU Invoice# Permit lD# <br /> Code INFO B as Remitted Service Re uest# <br /> D o.01> <br /> 42.02.001 ) a,Af ONSITE WASTEWATER PERMIT <br /> 12/2X!00) <br />