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j4D ONSITE WAF-EWATER TREATMENT SYS"'M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT[h ePARTMENT 304E WEBEk, V -3"'FL-STOCKTON CA 9$202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �f� .C'J._C7� CITY/ZIP <br /> CROSS STREET L )�'./j /�/Z�� APN ©9 7i1 Dob�/ PA/gC�EL SIZE ` o <br /> OWNERNAME G>'f f 6L / r' T/L'UC 1�-iI✓ln.. V•SN A! y'(S� tpn <br /> PHONE <br /> OWN ER ADDRESS CITV/STATE/ZIP 7 (' <br /> CONTRACTOR �L-/L/n�T'�L LI� <br /> 72-o 2- PHO-V-A) <br /> E <br /> 5 - TCONTRACTOR ADDRESS i K- -/ �/7 <br /> 7,0 J (^ <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST(S) NUMBER LAND USE APPLICATION <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION )b <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES! <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS (((N <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS (Yy" <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE f) <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL 11 FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PR (EDTHI$ PPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> / ST=/t'AWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> U 4 HOUR,ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> /,, 'i6'Cr//Q)�i DATE <br /> SIGNED \ � - < TITLE <br /> .)moi <br /> Z <br /> A Jp U IN <br /> F -AI li' LPrI 11N IDN <br /> HHH <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 5 Date /J 2 ,Ci3 Area -z- / Employee ID# <br /> Final Inspection By Date /,q/ /lam ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft; Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B as Remitted Service Request# <br /> 43-0I-001 ONSITE WASTEWATER PERMIT <br /> 1212/07 <br />