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r � - <br /> M , <br /> w ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3—FL-STOCKTON CA 95202-(204)468-3420 <br /> .NON-REFUNDABLE PERMIT - CALL 209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> '-,r� � L t-'� ;r, .. <br /> --- CROSS STREET T'..i --I'}�s, � .- APN C.- il 1Lf. PARCELSIZE <br /> OWNER NAME - <br /> P. <br /> ! ` <br /> OWNER ADDRESS •,f+r , ;I%-I.y l CITYI$T ATEIZIP - <br /> j <br /> r CONTRACTOR <br /> CONTRACTOR ADDRESS .'+r. G ✓r•3.. '.T�`''•i- W'.:3-/ CTrYISTATPJZIP L!. <br /> LICENSE ❑CA2 ❑C-36 r OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH! ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> i P-- PERCTEST #_ BUILDINGPERMIT# LANDUSEAPPLICATION# <br /> { FI' ri TYPE OF WORK: ❑ NEWINSTALLATION ❑ REPMRIADDITION Q ENGINEER DFSIGNED/ALTERNATIVE <br /> Yu! U REPLACEMENT ❑ DESTRUCTION <br /> Y INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL LI OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> Q SEPTIC TANK TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ti�•. ❑ GREASE TRAP TYPElMFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ PKG 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 /> A ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> R DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ` ft DEPTH ft <br /> y DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE fl <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WInTH fl LENGTH it DEPTH R <br /> --- DISTANCE TO NEAREST WELL ft FOUNDATION A PROPERTY LINE R <br /> ❑ SEEPAGE PITS NvkBER WIDTH ft DEPTH R <br /> 1 DISTANCE TO NEAREST WELL it FOUNDATION R PROPERTY LINE ft <br /> FI I 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INS RTIONS-PLEASE CALL(209053-7697 <br /> SIGNED l f r `~ - TITLE RATE <br /> I y I r v <br /> l <br /> j I y <br /> f +y <br /> Rk <br /> { <br /> i E <br /> I � <br /> 1 <br /> g44£ R � <br /> T y <br /> DEPARTMENT USE Oh'l/,Y <br /> k Application Accepted By !r�sU`--�--` Date r "�'7 Area Employee ID# f <br /> ----, Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PRISump Soil Character: <br /> COMMENTS <br /> Fi _ <br /> 5� PE SCReceived 'heck#! Amount Permit/! Code INF) B Cash ,Remitted Date Service Re uest# - Invoice# Permit ID# <br /> ! <br /> F1 .4122-11 7.' �' ti�- 'l-,f}4 j, �'•cr f. `�> 41 J; t�•: 7•� ,f.; tZ. �iJ i[' <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12YZVZO03 <br />