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ONSITE WAST <br /> �.�.VATER TREATMENT SYSTT ' PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AV�ND 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 //I L CITY/ZIP R �a/s/ �'s-.��3 7 <br /> CROSS STREET A l � r/IV r �/�6 A D APN �<� � "(��D ��� PARCEL SIZE 12-V <br /> 12-V r 4- <br /> OWNER <br /> OWNER NAME Met/�Je t �]� ,Qp/LiiInOb/ EI C–f yPHONE J 75-- `-C <br /> OWNER ADDRESS ,�•/0 i e,,,Il/IL. /-/7� J/ 9 CITY/STATE/ZIP / ���/S/C/l' 35—3 <br /> CONTRACTOR C/ I L-f lv` ] `,Cep`�1' a L T Z iV �j PHONE <br /> CONTRACTOR ADDRESS P- C/ , JBo 3-7Lj'g- CITY/STATE/ZIP r%�Llja� y S ? l <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WAT R TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> Fy PERC TEST(S) NUMBER JILAND 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 1't FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <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 <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ti <br /> I HEREBY CERTIFY THAT 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 /> UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> SIGNED ^� TITLE DATE <br /> 60 <br /> AQ IN CO N <br /> / r NV RO <br /> r3 L U <br /> 0 <br /> DEPARTMENT USE O LV <br /> Application Accepted By Date_ C! Atea _ Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil t pth t: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received heck Amount Date Permit/ Invoice# PermitID# <br /> Code INFO By Cash Remitted Service Re uest# <br /> 42-01-001 ONSITE WASTEWATER PERMIT <br /> 12'2!02 <br />