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I�4 � ONSITE,E)FIEWATER TREATMENT SYSTEM Ph---MT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 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 D t 1-2- E IA) CrrYlZm <br /> +- AA Fc[, n <br /> APN Oj'�—Z3 C: —CJI PARCEL SIZE 100 <br /> CROSS STREET - to <br /> OWNERNAME Lw� I ,P�AH}O.�NE,, �y� <br /> OWNER ADDRESS A I 1 7 {�+ Y1.( ,�Y�cy . CITYISTATErLip ,`� `-�sy` 9�ZZ i'- <br /> CONTRACTOR j-�t � <br /> CoNTRAcroR ADDRESS CITYISTATFIL1P <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER ExPIRATIoN DATE <br /> WATER TABLE DEFFH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> PEAC TEST A BUILDING PERMIT# LAND USE APPLICATION# PA - .-33-q <br /> TYPE OF WORK: CI NEW INSTALLATION ❑ REPAIRIADDrf1ON ❑ ENG4NEERDESIGNEDIALTERNATIVE <br /> ❑ REPLACEMENT ❑. Dwitu TION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LI V 940 UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> 0 SEPTICTANK TYPEIMFO CAPACITY gal A OF COMPARTMENTS <br /> (3 GREASE TRAP TYPEIMFG CAPACITY gal A OF COMPARTA4ENTS _ 5 <br /> ❑ PKC TX PLANT DISTANCE TD NEAREST. WELL fl FOUNDATION ft PROPERTY LINE fl }h- <br />` ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS N OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ FILTER RED Wow" ft LENGTH 11 DEPTH ft <br /> DT <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCEToNEAREST WELL ft FOUNDATION it PROPERTY LINE ft <br /> ❑ sumps WIBTTI fl LENGTH ft DEPTH it <br /> DISTANCETONLARESr WELL' ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTHft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WltrrH ft DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANDTHE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY.- <br /> MINIMUM H HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 _ <br /> SIGNED <br /> TITI.EI-'�J4.4JDATE 5�I5I��D <br /> � , � �z L•Cv � � p,FNc� �4J1�• tow�,.� �$ P/ <br /> I ❑ I � Mk' <br /> ---= J SA14 JOAOU. H A <br /> SITE PLAN <br /> i <br /> -A-A-I i 1 111 111A 11 ITLIA III LL 11 <br /> L DEPARTMENT US 9ONIA <br /> Applieation Accepted By Date 'a% Arca Employee IDA t <br /> Final Inspection By Date G/c ❑ SPECIAL PERMIT-Approved 6y <br /> Character of Sall to De of 3 Pit/Sump Sall Character: <br /> COMMENTS <br /> PE 5C Received Check#I Amount Permit/ <br /> Code INFO By Cash Remitted Date Service Request N Invoice A Permit IDA <br /> k <br /> 42-02.001 ONSITE WASTEWATER PERMIT <br /> 122212003 <br /> r <br />