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I <br /> y ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> M SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT 304 E WEBER AVE-3"'FL-STOCKTON CA 95202 -(209)468-3420 <br /> N011-REFUNDABLE PERMIT CALL 2119 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> 4l JOB ADDRESS 1 7 \ A L-)-,( t • CITYIZIP L�7. /5 1 <br /> I �1 7 Z-' ���7 {J PARCEL SIZE <br /> I CROSS STREET -� p r (� APN 4 c'k <br /> OWNER NAME �1 Y (� 1 1 TiL- �"�-�,Ji PHONE { Imo/ <br /> OWNER ADDRESS CITVISTATEIZIP <br /> F, CONTRACTOR <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />{ _ PERC TEST H BUILDING PERMIT# LAND USE APPLICATION#2 f-,'f�`t/" <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ RuAIRIADDITION ❑ ENGINEER DESIGNED IALTERNATWE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ILII p SEPTIC TANK TYPEIMYG CAPACITY gal #OF COMPARTMENTS <br /> I y <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> t <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R ' <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH A LFNGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL fl FOUNDATION R PROPERTY LINE ft ; <br /> _ ❑ MOUNDED WIDTH A LENGTH ft DEPTH 11� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE ft <br /> 11SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION D PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMaER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ft <br /> -- I HEREUY 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- 1-F.ASECALL(209)9$3-7697 f 1 <br /> hSIGNED—#--.i ..•-t...-.�I ,}--.c-� � '- TITLE r'..----• + .. .-..n DATE <br /> I <br /> k F,` III I I I I I J -, <br /> k <br /> LAI i <br /> V <br /> i <br /> J 11111JAU <br /> r <br /> $ W.,J I <br /> A <br /> � i <br /> - 'r I DEPARTMENT SE NLY' cc,� <br /> Application Accepted Byf --�`i�/../ `- � Date V(++ Area Employee ID#J <br /> Final Inspection By .Date © SPECIAL PERMIT-Approved,by <br /> - Character of Sall to Depth of 3 Ft: PitlSump Soil Character: <br /> COMMENTS <br /> Fj <br /> _ pE SC Received Checl}#L� Amount Permitl <br /> Code INFO B Cash Remitted Date Service Request <br /> $ Invoice# Permit IDtt <br /> 42-02-001 <br /> ONSITE WASTEWATER PERMIT <br /> nn�nnna <br />