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Siam <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT 304 E WEBER AVE - 3"° FL- STOC:KTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT/• CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />^ <br />AD <br />Y ( / � (If ^• L A Itis CITVl"LIP <br />J�-OG•F'Iil fN � <br />y <br />(' 11.7 <br />iA 10 <br />` 7 <br />O <br />CROSSSTREET <br />W APN --9aO <br />PARCELSIZE <br />0 <br />OWNER NAME OJ <br />PHONE G l0�y 1 <br />A <br />OWNF.RADDRESS <br />.S c. .^� (� CITY/STATE/ZIP <br />CONTRACTOR <br />1- ce 4 JL Se (tti C,,- <br />L/ ` <br />PHONE <br />CONTRACTOR ADDRESS <br />CrrV/STATE/ZIP <br />r <br />LICENSE ❑ C-42 <br />❑ C-36 OTHER NUMBER <br />EXPIRATION DATE moi? <br />WATER TABLE DEPTH: <br />fl GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />❑ PERC TEST # <br />BUILDING PERMIT # LAND USE APPLICATION # <br />TVPE OF WORK: <br />NEW INSTALLATION ArREPAIR/ADDITION <br />❑ ENGINEER DESIGNED/ALTERNATIVE <br />❑ REPLACEMENT ❑ DESTRUCTION <br />INSTALLATION WILL <br />SERVE: RESIDENCE ❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: J <br />NUMBER OF EMPLOYEES: <br />�. <br />❑ SEPTIC TANK <br />TYPE/MFG CAPACITY <br />gal # OF COMPARTMENTS <br />I <br />❑ GREASE TRAP <br />TYPE/MFG CAPACITY <br />gal # OF COMPARTMENTS <br />❑ PKC TX PLANT <br />DI.STANCETO NEAREST: WELL ft FOUNDATION _ <br />ft PROPERTY LINE fl <br />❑ LIFT STATION <br />TYPE OF PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />^\ <br />` <br />a, LEACH LINES <br />�SILlE " <br />W LEACHING CHAMBERS L "H a OF LINES _� <br />LENGTH OF LINES L101 fl <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE fl <br />❑ FILTER BED <br />WIDTx ft LENGTH It <br />DEPTH It <br />_ <br />DISTANCE TO NEAREST WELL R FOUNDATION <br />R PROPERTY LINE It <br />❑ MOUNDED <br />W'IDT'H fl LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL. ft FOUNDATION <br />R PROPERTY LINE it <br />n <br />❑ SUMPS <br />WIDTH ft LENGTH __ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL fl FOUNDATION <br />ft PROPERTY LINE fl <br />❑ DISPOSAL PONDS WIDTH III LENGTH ft <br />DEPTH fl <br />DISTANCE TO NEAREST WELL Il FOUNDATION <br />ft PROPERTY LINE it <br />911--s-FEPAGE PITS <br />NUMBER WIDTH $GLI ft <br />DEPTH 15 1 fl <br />DISTANCE TO NEAREST WELL Il FOUNDATION !.)( <br />ft PROPERTY LINE J~41 fl <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQVIN COUNT!" <br />ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIM ;M 24 HOUR ADVANCE NOTICE. REQUIRED FOR INSPECTIONS- PLEASE, CALL (209) 953-7697 <br />SIGNED <br />c� <br />TITLE 'I A 'ly C c f u {� DATE 1 D <br />IG <br />i <br />0 <br />y <br />('4 <br />I <br />LE EP <br />�1 <br />MP ARTMENT SE O. Y -------- <br />- _ <br />Application Accepted B <br />—Dalc Area <br />Employee ID# . <br />Final Inspection By <br />Date ❑ SPECIAL <br />PERMIT -Approved by <br />Character of Soil to Dept of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS CkLI7 <br />1,tir OF �r'1�f?ih <br />PE SC <br />Received heck# Amount Date Permit/ <br />Invoice # Permit III <br />Code INFO <br />By ash Remitted Service Request # <br />Z 05- <br />1' Rev yg Z b3 <br />42-02-001 <br />ONSITE WASTEWATER PERMIT <br />1 212 212 003 <br />