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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT - v <br /> SAN K-REF'UNDABL <br /> COUNT 'RONMENTAL HEALTH DEPARTMENT 31'-WEBER AVE-3-FL-STOCKTON CA 95202-(209)468-3420 <br /> NRMIT CALL(209)953-7697 FOR INSPI NS XPIRES I YEAR FROM DATER <br /> W <br /> JOB ADDRESS CITY/ZIP V � <br /> IV <br /> ----�►►►------ — a <br /> CROSS STREET / v�� APN 10 [ D2'"o-0 PARCEL SIZE_ 4 <br /> � / In r D <br /> OWNER NAME ��� N Ii T�� PHONE (4 <br /> OWNER ADDRESS T CITY/STATE/ZIP /�( <br /> CONTRACTOR 7 '' PHONE 361 <br /> � <br /> CONTRACTOR ADDRESS R 61 CITY/STATE/ZIP <br /> LICENSE -42 ❑C-36 OTHER NUMBER 2 7--s EXPIRATION DATE d La G <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y ' <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: IDENCE ❑ COMMERCIAL +� ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS , <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LINE R i <br /> ❑) LIFT STATION SIzE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) �\ <br /> RC—LEACH LINES .LEACHING CHAMBERS #OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL 120 R FOUNDATION R PROPERTY LINE R <br /> ❑ FILTER BED WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH R -LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE fl <br /> ]� SEEPAGE PITS WIDTH ft LR DEPTH ft <br /> ' ` DISTANCE TO NEAREST WELL ft FOUNDATION ��_ft PROPERTY LINE R <br /> 1 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 /> T UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INS PE 'IONS-PLEASE CALL(209)953-7697 <br /> SIGNED MINIM %�' -�d CI7'I'LE DATE 1 <br /> 17 <br /> I <br /> AN <br /> i <br /> bA <br /> G <br /> P N M <br /> S O <br /> lo <br /> DEPARTMENT PSE ONLY <br /> Application Acce d By Date 3 Area [Z Employee ID# <br /> Final inspection Dale3�iLa/V,y ❑ SPEC IPERMIT-Approved by <br /> Character of Soil to Depth 3 Ft: PltlSump Soil Character: <br /> CO ENTS P( .�I�tis[ Se 1e--S,+-45-0 4.4lt9ef e�eo6. II S OJ fr(S) <br /> PE SC Received ec / Amount Permit/ <br /> Code INFO B ash emitted Date Service Request# n e t <br /> D � <br /> 42-01-001 <br /> 12/2/02ONSITE WASTEWATER PERMIT <br />