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ONSITE WASTEWATEF XATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT *%.Wl 304 E WEBER AVE-3""FL-STOCKTON CA 95202 -pl1)J/ <br /> 468-3420 <br /> NON-REFUNDABLE P RMIT _ CALL(209)9�3-7697 FOR INSPECTIONS EXPIRES 1 l"EAR FROM DATE ISSU D <br /> JOB ADDRESS t CITY/ZIP (- M u U— r <br /> G� X16 i YK S <br /> CROSS STREET N ��") IV APN PARCEL SIZE <br /> 0 <br /> OWNERNAME T/�„ fcw.IJe S PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR ? fl/ I tw/l ,Bull r,t-t l PHONE. ','c7 1U, <br /> 2z HvLAstT./% t-n. LUCII' ( c, 9', 2 !u <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST(S) NUMBER S LAND USE APPLICATION# MS <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 MPLOYEES: QA <br /> ❑ SEPTICT.ANK TYPE/MFG CAPACITY gat #OF COMPAiTMENTS -.44 <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS CNI <br /> a= M <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> r❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES fl �- <br /> DISTANCE TONEAREST WELL R FOUNDATION ft PROPERTY LINE ft --� <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH 11 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft "^,j <br /> ow EI MOUNDED WIDTH It LENGTH R DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH R -DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> was DISPOSAL PONDS WIDTH tt LENGTH R DEPTH_ R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ SEEPAGE PITS WIDTH R LENGTH rt DEPTH R <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE - ft <br /> r I HEREBY CERTIFY THAT4.HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 1 1 4 HOUR ADVANCE NOTICE REQUIRED FOR IN CTIQNS-PLEASE CALL(209)953.7697 'I` ;?o <br /> SIGN TITLE l� C t DATE <br /> L — -- <br /> Z Ia:)iod �aiJod i <br /> �_ 7II y/ a✓ d ,_ <br /> 4/ L <br /> ---- - - - I (1 in =660ft.) - } <br /> avoa -_=s31mos <br /> DEPARTMENT USE ONLY 2 Ph G <br /> ` Application Accepted By �'� Date rj!d- .l 7 Area I Employee ID# (� <br /> —T <br /> Final Inspection By Date' ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SCReceived #/ Amount Date Permit/ Invoice# Permit I <br /> e INFO Bv' Cash Remitted Service Re uest# <br /> 11010 42-01-001 <br /> ONSITE WASTEWATER I ERNI IT <br />