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ONSITE WARTEWATER TREATMENT SY ;M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL H&U EPARTMENT 304 E WEBS.- :,rE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7197 FOR INSPEC.'TIONS EXPIRES I YEAR FROM D TE ISSUED <br /> " V CITYIZIP <br />' <br /> JOB ADDRESS 4n/ <br /> CROSS STREET 1"s��`X C/� - ' f 0- 3�__ PARCEL SIZE �a V <br /> APN ��3 "` a <br /> V <br /> v <br /> / {i A <br /> OWNER NAME/ Ir` I � 6• +r e-, PHON <br /> WNER ADDRESS �fJ /J { TYISTATE/ZIP <br /> CONTRACTOR] PHONE -� <br /> CONTRACTOR ADDRESS r r C YISTATEIZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NU ER EXPIRATION DATE <br /> WATERTABLE'DEPTH: ft GEOGRAPHICAL INFORMAT : Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# \} <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRJADDITIN 13 �3NCINEER DESIGNED/ALTER ATIVE <br /> L) REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIA ❑ OTHER t \ <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS {� <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FO t PROPERTY LINE ft <br /> i <br /> ❑ LIFT STATION SIZE TYPE OF PUMP CWYDSEPARATOR(ENCLOSED SYSTEM} <br /> I <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> t DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> k <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 ft <br /> ❑ 5UMP5 WIDTH ft LENGTH ft DEPTH ft <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 fl <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> �. DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMU OUR VANC CE REQUIRED FOR INSPECTIONS—PLLASE C 19)953:=769A/l7 <br /> Cl <br /> 1GNf3p TITLE r DAT: F (J� <br /> I <br /> P I <br /> I <br /> I <br /> AU V 0A <br /> Ilk FP4 't-It V <br /> I <br /> -144 <br /> gM pr.-�jjN <br /> L� 1 <br /> u <br /> EPARTME'NT USE NLY - <br /> Application Accepted B Date 3 Area e Employee ID# <br /> Final InspectionDate /Z—7Z IJSPECIAL PERMIT-Approved by <br /> Character of Soil to De hof 3 Ft: _ Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received C CheckE Amount Date Permit! Invoice# Permit ID# <br /> Cade INFO B ash Remitted Service Reg nest# <br /> 1 75- '%W— Ji 303 'R 3 a3 <br /> 42-01-001 <br /> 1212/02 ONSITE WASTEWATER PERMIT <br />