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16P oa a C.3(l <br /> 4NSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SIAN 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 EXPIR�ES�"I YEAR FROM DATE ISSUED <br /> JOB ADDRESS Ly, c� CITY/ZIP <br /> CROSS STREFT ,yam APN D-i� PARCEL SIZE C/ <br /> C <br /> M <br /> OWNER NAME 0 G rix N1 q PHONE � <br /> OWNER ADDRESS c,%A CITYISTATEJZIP <br /> CONTRACTOR _ r. /PHONE. 4e "I 9& �(if tr <br /> CONTRACTOR ADDRESS CITY/STATEJZIP /+'1 044-",f <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE ��� <br /> WATER TABLE DEPTH: ) ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINF.F.R DESICNEDIAI-TERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION � �11 <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 4 NUMBER OF,EMPLOYEES:SEPTIC TANK TYPEIMFG �L CAPACITY [fi gal #OF COMPARTMENTS d; <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL 1 O O ft FOUNDATION p f? PROPERTY LINE ���ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> E LEACH LINES ❑ LEACHING CHAMBERS #OF LjNES Ck _ LENGTH OF LINES d ft <br /> DISTANCE TO NEAREST WELL ! [51 ft FOUNDATION �O I ft PROPERTY LINES / ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL _ F1 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 (5 ft <br /> DISTANCE TO NEAREST WELL iambi ft FOUNDATION. ICI ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DFPTH 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 ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953.7697 <br /> SIGNED _ TITLE :��Vv 7 >r`�� D _ DATE4 D <br /> Q•f 1 <br /> I � <br /> 1 <br /> Al J AO IN O N <br /> EN flRQ ME <br /> DEPARTMENT SEZOLV <br /> Application Accepted P Date i Area Employee 1Q#��(C <br /> Final Inspection R Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PI u p Soil Character: <br /> COMMENTS o �7 <br /> r <br /> PE SC Received CCheck# Amount Date Invoice# Permlt ID# <br /> Cod:• INFO H ash Remitted erv' <br /> !0 p UPS <br /> 42.01-00] <br /> 12/2;02 ON51TE WASTEWATER PERMIT <br />