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ONSITE WAST 'ATER TREATMENT SYSTY PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP— ,MENT 600 E M., fREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT VALL 209 953-7697 FOR INSPECTIONS ��JEXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS G.� 00oC P ldl�i✓76(,,I7' t.-6y y <br /> CROSS STREET �7/�/ © APN Z 22 PARCEL SIZE 3^ �y <br /> OWNER NAME 5: A <br /> 4 ;/ � VAJ C <br /> PHONE /� f <br /> (� 9 D / �+ ! <br /> OWNER ADDRESS A / L�'v�,Z�l4U- ' #6+ "' CITY/STATE/ZIP xRe�yr^ p <br /> CONTRACTOR ` �- PHONE :5.1 <br /> CONTRACTOR ADDRESS ^ CITY/STATE/ZIP 494 <br /> LICENSE ❑ C42 ❑ C-36 OTHER NUMBER �('T EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION (3 REPAIR/ADDITION L) ENGINEER DESIGNED/ALTERNATIVE <br /> O REPLACEMENT STRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft qQ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft p V <br /> O MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ) <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft (C <br /> O DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft C <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO 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 <br /> ORDI ANCES,SATEjqkWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> NIM R ADV NOTICE REQUIRED FOR INSPECTIONS <br /> ?PLEASE CALL(209)953-7697 <br /> SIGNED TITLE (___�/�/ fz DATE ® �� <br /> me cov,xo nnrws euc nua.Win...,.._..._ -..:.. '...•..... - <br /> YMENT <br /> N <br /> �/1E� d ��,_ / h q'clpnI r, H H EP Et,TAI NT <br /> l ' <br /> SEP 17 1996 <br /> Y, <br /> eNvi( <br /> DEPARTMENT USE ONLY !f r L Sy <br /> Application Accepted By Date /_OT`07 Area Employee ID# 4(d"ES �Grn <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#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> zfuf 07S 93 (OE •0-1) lb D 0052 :3 <br /> 42-01 ONSITE WASTEWATER PERMIT <br /> nc nnnnm <br />