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ONSITE WASTEWATE IEA'IMENT SYSTEM PERMIT <br /> ­,iAN JOAQUIN <br /> {COUNTY ENVIRONMENTAL HEALTH DEPARTMENT `� 304 E WEBER AVE-3"FL-STOCKTON CA 95202-T209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL <br /> I�� CAL�^L(209)953`-776.{97 FOR INSPECTIONS /� EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS / �7 Y 11.E 1 V � I I t Jl ll.1 CITY/ZIP C_[C.1 i LC.V I�� �G- I•._r LA <br /> I <br /> ROSS STREET N w 1 13 6 APN C'19-JV'1 C -r-)' PARCEL SIZE fT 6r_ o <br /> o <br /> OWNER NAME <br /> M v Ti' [, I' :)i)I PHONE � �f '] <br /> 3WNER ADDRESS • ��' CITY/STATE/ZIP C�L.bIlC.11i) CA JJ G'^t­ <br /> CONTRACTOR NQ1 PHONE ; -_' <br /> CONTRACTOR ADDRESS 9C1.2ICI `�I t CITY/STATE/ZIP Lr ,' <br /> ACENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> `rVATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X V <br /> TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE J <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> ,.NSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> 7 SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> LI PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ LIFT STATION SIZE— TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ,al] LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES It J <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH ft n <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> y] MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fr <br /> ] DISPOSAL PONDS WIDTH ft LENGTH R DEPTH ft <br /> a. <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft f'� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft C, <br /> am 1 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 /> MINIMUM 22-4 Ht DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> iIGNED %/ T� T_-"-`-- TITLE DATE <br /> I <br /> tT <br /> jOkO I C U I, <br /> E NVIR0 Nly N AL <br /> lik—l-Ir U-1 <br /> �( <br /> DEPARTMENT lIS ON Y 1 1Z j�G y <br /> Application Accepted By �i"" Dale 2 G Area Employee ID# <br /> final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> :haracter of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Checidi�' Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> iNQ-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />