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ONSITE WA•.4EWATER TREATMENT SYS.. M PERMIT /0v <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"'FL-STOCKTON CA 95202 <br /> - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / <br /> CITY/ZIP <br /> / / ? <br /> CROSS STREET L r APN (�� " GJ •� S�� PARCEL SIZE Cr7- J �� > <br /> OWNER NAME <br /> v <br /> ili�l✓ r PHONE N <br /> OWNER ADDRESS / ��ji L/ �� CITY/STATE/ZIP_ <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS ' A l �<��f <br /> ITY/STATE/ZIP �2l ',v ,•_O <br /> LICENSE ❑C-42 ❑C-36 OTHE NUMBER '- ] EXPIRATION DATE •- (,`, (; , <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# .- LAND USE APPLICATION# S —7 <br /> TYPE OF WORK: NEw INSTALLATION L3REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION C� <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: n NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG4i'T)C. / CAPACITY 2�: ��G O!; gal #OF COMPARTMENTS Z21 <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 /> EJ <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #of LINES LENGTH OF LINES ft f' <br /> DISTANCE To NEAREST WELL fl FOUNDATION ft PROPERTY LINE ft <br /> �T7LTER BED WIDTH may(/ ' ft LENGTH /70 ft DEPTH tz, L" '0 V ft <br /> DISTANCE TO NEAREST WELL SG G 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 r' <br /> f <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 NUMBER WIDTH ft DEPTH ft ^` <br /> r <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> I 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 /> MINIMU>fl HOUR ADVANCE NOTICE REQUIRED FORINSPECT NS-PLEASE CALL(209)953-7697 <br /> SIGNED 7 L - TITLE DATE <br /> r - <br /> 2 ;w <br /> JAN <br /> CL C' <br /> T M N"A ITA ry <br /> I- <br /> r CLSI <br /> 14+ <br /> ��� DEPARTMENT SE OLY <br /> Application A C�: '� r Date C'� Area Employee ID# <br /> Final Inspecti By �3Ft: <br /> Date ��.���� ❑ SPECIAL PERMIT-Approved by <br /> Character ofSoil to DPit/ ump Soil Character: <br /> COMMENTS t:� t_c o { �_- ,c 2 Q OM �k _ S _7M- AS•T­X t.-L_ - [v <br /> PE SC Received eck#/ Amount Permit/ <br /> Code INFO By as Remitted Date Service Re uest# InsoF�e vml <br /> z1G .2s ti \\1A z_ <br /> CP <br /> 42-02-001 ,� `7� u 1.�� "�� -"' ONSITE WASTEWATER PERMIT <br /> 12/22/200 <br />