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rt7� 2iJ f -z I <br /> - — ONSITE WASTE .TER TREATMENT SYSTEA ERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPAR'i, ,, N'F 304 E WEBER AVE - - del,-STgCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS r L C[FY/GIP /. ti <br /> CROSS STREETI" ✓•..� .. APNy){(J C4. a <br /> PAKCEL SiLE 0 <br /> O%A,NERNAME i �.�L✓G ��i�1iyi/JI/c iCm <br /> .I .. ... PHONE � ��" y <br /> OWNER ADDRESS _l�'�a� CITY/SPATE/Zill . <br /> CONTRACTOR PHONE MU412_4�;Z7_7 <br /> CONTRACTOR ADDRESS } ���%���� / �r- - Cl'rY/S'I'A'FE/ZIP_C <br /> LICENSE gC-42 ❑C-36 OTHER NUMBER $ Qy5 EXPIRATION DATE UV { <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X y (1 <br /> © PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION f AK <br /> REPAIR/ADDITION 0 ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENTr4pla ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: lj NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG—, . CAPACITY � gal #OFCOMPARTMENTS <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 /> i <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES _ LENGTH OF LINESU r ft <br /> a <br /> DISTANCE To NEAREST WELL7�It FOUNDATION_. ft PROPERTY LINE_-_ ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE it <br /> ❑ MOUNDEb WIDTH R LENGTH ft DEPTH H <br /> DISTANCE TO NEAREST WELL ft FOUND 10ft PROPERTY LINE ft <br /> El sumps WIDTH ft LENGTH tt DEPTH ft' <br /> DISTANCE TO NEAREST WELL TION ft PROPERTY LINE ft <br /> ❑ DISPOSAI,PONDS WIDTH ft LEN ft DEPTHtop <br /> 1t <br /> DISTANCE TO NEAREST WELL OUNDATION ft PROPERTY LINE ft <br /> �— SEEPAGE'PITS WIDTH IV It LENG ti DEPTH <br /> DISTANCE TO NEA REST YWELL fl FOUNDATION -_.-�(J 1t PROPERTY LINE <br /> I HEREBY CERTIFY THAT 1 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE / DATE D 03 <br /> 1 <br /> i <br /> i <br /> 1 <br /> .a <br /> 1 <br /> 7 <br /> r <br /> t f.. <br /> 3 <br /> t <br /> DEPARTMENT YSE PNLY <br /> Application Accepted Date Area r Employee IDM S <br /> Final Inspection Date 1�� �f� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to DeA31F Pit/Sump Sail Character. <br /> COMMENTS <br /> PE SC Rcccived Chccw Amount Date Permit/ ]"voice# PermitID# <br /> Code INFO B ash Remitted Service Request# <br /> 42-01.001 <br /> 12/2/112 ONSITE WASTEWATER nwrr <br />