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ONS WASTEWATER TREATMENT SYS .:VI PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-3-FL-STOCKTON CA 95202 -(209)469-3420 <br /> NON-REFUNDABLE PERMIT CAI,1,(209)953-7697 PON INSPECTIONS EXPIR S 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSOZ? 6 2e-41 / 7CITY/ZIP 2 f /G y <br /> CROSS STREET APN%:_3— ,03 Y <br /> 9� / PARCEL C <br /> OWNER NAME PHONE — 07a,,6 <br /> OWNERADDRESS �J'T•'/ CITY/STATE/ZIP <br /> CONTRACTOR Imo. _;r'Le' PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -42 13C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X V <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DFSIGNED/ALTERNATIVE <br /> REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMCBER OF BEDR MS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG /ii' b'- J CAPACITY QC/ gal #OFCOMPARTMENTS ,� <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL Aaci ft FOUNDATION ft PROPERTY LINE ft \ <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) �n <br /> b< LEACH LINES L3 LEACHING CHAMBERS_ #OF LINES� LENGTH OF LINES ft ^\S <br /> DISTANCETO NEAREST WELL 100 ft FOUNDATION _ ft PROPERTY LINE ft \� <br /> ❑ FILTER BED WIDTH 11 LENGTH ft DEPTH ft I <br /> DISTANCETO 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 /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEFTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1� SEEPAGE PITS NUMBER _WIDTH 3,.S` ft DEPTH OC 5� ft <br /> DISTANCE TO NEAREST WELL__/4� Q ft FOUNDATION //ri�L it PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 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 /> T MI tUM 24 HOUR ADVANCE NOT[ E REQUIRED FOR INSPECT.I, S-PLEASE CALL 4209)953-7697 <br /> SIGNED 5�� f SOO 1 DATE <br /> v <br /> HF '/ f1 <br /> IUI <br /> S� P <br /> L <br /> i <br /> «I <br /> _... _.. -DEPART 'T U ON V <br /> Application Accepted Date G Area � Employee ID# I I <br /> Final Inspection B ' Date ❑ AL PERM <br /> SPECIIT-Approved by <br /> Character of Soil to Dep f 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS S/Z--w XZ7ZkA1v .MS r✓72--` •- !P12,,Aze, <br /> PE SC Received Checldt1_ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br />