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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT j go <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE -3—FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYIZIP -{2'✓y`4� T <br /> l 7GG^^ N <br /> CROSS STREET -cc� 'c APN �� / 2/I/ /S PARCEL SIZE e <br /> 0 <br /> OWNER NAME DZ7 f,�,4 /ee i p� PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP a <br /> CONTRACTOR - PHONE 3Gel--57T7 <br /> CONTRACTOR ADDRESS CTTY/STATE/ZIP <br /> LICENSE V C42 0C-36 OTHER NUMBER EXPIRATIONDATE <br /> WATER TABLE DEPTH: H GEOGRAPIUCALINFORMATION: Coordinates X y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION d <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER 3 <br /> NUMBER OF LIVING UNTTS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ry <br /> �L SEPTIC TANK TYPE/MFG S://-�} CAPACRY .X,cV gal #OF COMPARTMENTS �L� V <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal If OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCETO NEAREST: WELL a''$ZJ ft FOUNDATION S ft PROPERTY LME 79-' ft <br /> O LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> r 35—LEACH LINES 9-LEACHING CHAMBERS Z� #OF LINES_� LENGTH OF LINES fC3 j R <br /> DISTANCE TO NEAREST WELL A/�. ft FOUNDATION )- ft PROPERTY LME It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL H FOUNDATION H PROPERTY LME It <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH R LENGTH R DEPTH R <br /> DISTANCETO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> SEEPAGE PITS NUMBER S/ WIDTH 0". It DEPTH _ 2s--, ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION 5h' ft PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT I 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE J jam,. DATE Za/ _ <br /> � �I <br /> lilt <br /> J A UI <br /> N IR N ETA / <br /> a XF 1/ <br />