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ONSITE WAS] 'VATER TREATMENT SYST' I PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AN""3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT {fit CALL(^209)953-7697 FOR INSPECTIONS �jEXPIRES I YEAR FROM DATE ISSUED <br /> A <br /> JOB ADDRESS �7 ic}s f'/iL� LIV67 CITY/ZIP / -�/'C�/V <br /> CROSSSTREET A 5rllki /' ol4i) APN 22-0- 0 —Q� PARCELSIZE 20, <br /> //JJ�� / ,may .yam �j 7vo <br /> OWNER NAME X �I�}L �i% VI'10o J `�� PHONE 6-7S-� 4 L� y <br /> OWNER ADDRESS / / '"`" �JC/► �' CITY/STATE/ZIP /"�opa�s// o 9j 33 3 <br /> CONTRACTORyLL-r/ �� PHONE <br /> CONTRACTOR ADDRESS _ F(/ '3-17q4- CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATE ABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST(S) NUMBER LAND USE APPLICATION# <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 EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG 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 #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH_ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I'll <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ? <br /> 1" <br /> I HEREBY CEZT I 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 /> M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 j <br /> SIGNED TITLE 11Gkyn/ DATE 7, <br /> T <br /> ) <br /> N �- <br /> J <br /> DEPARTMENT USE ONLY <br /> Application Accepted By /,17Date !/ (✓' Area ;� Employee ID# q3-7 <br /> Final Inspection By Date e2 El SPECIAL PERMIT-Approved by <br /> Character of Soil to hof t: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC ReceivedCheck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> 42-01-001 ONSITE WASTEWATER PERMIT <br /> 12%2!02 <br />