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ONSITE WANwiJ WATER TREATMENT SYSTEM PE._ HT <br /> _ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REI+UNDABLE PERMIT - CALL(20919534-7697 FOR INSPE 'TIONS E-- RES 1 YEAR FROM DATE ISSUED <br /> f-(� o Y-e (' 1` CITV/ZIP (MPT <br /> r <br /> JOB ADDRESS rl <br /> CROSS STREET APN PARCEL SIZE C <br /> FIC,I v; In 1 1 1 PHONE JQ�� y <br /> OWNER NAME � J �,.,L��1� <br /> JJ f <br /> l Y C L..1 7 i L ��i r: (1 o Y'L` IL C� CITV/STATFIZIP (L•'_7 1 ( �� '�C�,�'(( /) <br /> OWNER ADDRESS 1 (!, ���/,�'yyy� - y <br /> CONTRAC 0R 1 ( `-� rl y` �:l -cv� J�1lG 1—/f l� PHONE <br /> /G j I C:IU ,11 ICS <br /> CONTRACTOR ADDRESS CITV/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PER TEST(S) NUMBER LAND USE APPLICATION# _ <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE N <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: G <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS I, <br /> _, ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCETO NEAREST: WELL III FOUNDATION R PROPERTY LINE ft ! <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) O <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft T, <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft J <br /> a ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS WIDTH R LENGTH ft DEPTH ft 7D <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> i STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> ( _N1jNIM`M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPE TIO;'S-PLEASE CALL(209)953-7697 l/ <br /> �) Rf✓C0 E'Iv1Y�t� /[i /) <br /> SIGNE , /"` TITLE c DATE <br /> V — � <br /> t <br /> t I � <br /> s <br /> f <br /> .1 <br /> O qM N EN <br /> DEPARTME[VT' <br /> / L� L <br /> Application Accepted By 1�.tfZ - Dete / / t7 / Area " Employee ID# 5 <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received `Check#r Amount at Permit/ Invoice# Permit ID# <br /> Code INF B Cash Remitted Service Re uest# <br /> 42-01-001 ONSITE WASTEWATER PERMIT <br />