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ONSITE WASTEW"A TER TREATMENT SYSTEM D'`•RMIT // du <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART410 304E WEBER AVE -3" STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EX PIRES i YEAR FROM DATE ISSUED <br /> /J N <br /> JOB ADDRESS ' 1 CITY/ZIP I m <br /> APNyGc/ �O -7O PARCELSIZE /Y 1 p <br /> CROSS STREET rWC"'/� �/� <br /> OWNERNAME 1 KP+'��If�.� r`�` I�}•r` PHONE _[ DI�Q� � <br /> OWNERADDRESS 1,' '-, }y.�M /1� CITVISTATE/ZIP 1,1NDF'y —�"/'/I'`���� <br /> COrTRACTOR D I f�V(Y1 1�T /'��J(�7/P7�Y PHONE -"1 �� <br /> CONTRACTOR ADDRESS ?o L/�X —`W CITV/STATE/ZIP LOO, ,� S <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PER TEST(S) NUMBER LAND USE APPLICATION# <br /> YPE 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 /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL R PROPERTY LINE it <br /> ❑ FILTER BED WIDTH H LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL F ATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH H LENGTH ft DI:PDI ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH 11 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH R DEPTH 11 <br /> DISTANCE TO NEAREST WELL H FOUNDATION D PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> SI'A'TV.LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIN M UR ADVANCTICE REQUIRED FOR INSPF .IONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE �✓ � DATE 7 t L4 <br /> -L3-cxJ <br /> vI 3 <br /> Q I s, I I i <br /> -347 <br /> 7 <br /> I 1 <br /> I <br /> DEPARTMENT SE O LY �.1�EpLTH DEPAflT T - G� <br /> Application Accepted By -:T' Date Area ( �7 _ 'employee ID# �y(/ <br /> Final Inspection y Daft? ❑ SPECIAL PERMIT-Approved by <br /> Character of Sol th of 3 t: Pit/Sump Soil Character: <br /> COMMENTS i <br /> PE SC Received hec Amount D to PermiO Invoice# Permit IDN <br /> Code INFO B Cash Remitted Service Request# <br /> a C <br /> 42-0I-001 ONSITE WASTEWATER PERMIT <br /> 122/02 <br />