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ONSITE WASTEWATI 'REATMENT SYSTEM PERMIT yo'I/ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT *A/ 304 E WEBER AVE-3"'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 E eJim CITY/ZIP n y <br /> CROSS STREET n APN \J ,(-' i q e '- I PART FA.SIZE 0. 3 <br /> OWNER NAME E \( <br /> 'I{ (J /� 1. PHONE <br /> rl <br /> OWNERADDRESS Z� / �I�C r u n 3 CITY/S'1'A'FE/%II' ✓ 'v(- r�+ .• <br /> ff <br /> CDNV <br /> rRACTOR W 11 C PHONE <br /> CONTRACTOR ADDRESS <br /> LICt.NSF. ❑C42 ❑C-36 011n:R NUMBER EXPIRA"PION DAT!: <br /> WATER TABLE DEPI'll; 11 GEOGRAPHICALINFORMATION: Coordinalc.s X <br /> ❑ PERC TEST(S) MIMI..R I AND USI:Al I'I II A I RIN II _ <br /> TYPE OF WORK: ❑ NEW INSTALLATION_- -- -❑ REPAIR/ADU 'ON ❑ i:N(:INEl:R DESIGNED/ALI'ERNA'I'IVE <br /> ❑ REPLACEMENT DESTRUCTION �!'1 <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER e, <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> (v <br /> ❑ SEPTIC TANK TYPF/MFG CAPACITY gal p OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal p OF COMPARTMENTS C/ <br /> ❑ PKG TX PLANT DISTANCETO NEAREST: WELL R FOUNDATION tl PROPERTY LINE tl <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS k OF LINES LENGTH OF LINES IT <br /> DISTANCETO NEAREST WELL fl FOUNDATION A PROPERI"LINE II CL_ <br /> ❑ FILTER BED WIDTH 11 LENGTH ti DEPTH_ _ 11 <br /> DISTANCE TO NEAREST WELL Il FOUNDATION Il PROPEKI"i'INE IT <br /> ❑ MOUNDED WIDTH IT LENGTH It DEPTH II <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE fl <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH ft <br /> D15TANCETO NEAREST WELL A FOUNDATION 11 PROPERTY LINE tl <br /> ❑ DISPOSAL PONDS WIDTH 11 LENGTH Il D¢P'ill Il <br /> DISTANCE'r0 NEAREST WELL A FOUNDATION Il PROPERTY LINE Il <br /> ❑ SEEPAGE PITS WIDTH fl LENGTH fl DEPTH Il <br /> DISTANCE TO NEAREST WELL Il FOUNDATION B PROPERTY 1.11 E A <br /> 1 IIEREtlYTHAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> .S'I'nTE LA WS AND RULES ANU REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HO;IR )VAN F NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL RlW)953-7697 (� <br /> SIGN D _ TITLE DATE <br /> r <br /> r <br /> 1 <br /> E I E <br /> I ,A' <br /> isi <br /> Y <br /> DEPARTMENT USE ONL ' ENVIRONNIENTAL HEALTH DIVI ION <br /> Application Accepted I Datee Arca 2I Employee 00 el <br /> Final Inspection �J�(7�in Date J�� Z-� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil o h of 3 Ft: <br /> Pit/Sump Soil Character: <br /> COMMENTS Z.�/0 rr _ss ovr� /J _l ^� <br /> PE SC Received Chcc W1/- Amount Ualc Permil/ <br /> Code INFO B C-h Rcmflled Scrvlcc Iter uest q Invoice N I'rnnil IUq <br /> 1 00 3 461 5 <br /> 42.01.001 <br /> ' ONC11T N'ASTFWATFR PERMIT <br />