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ONSITE WASTEWATER TREATNT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-3"°FL-STOCKTON CA 95202 -(209)468-3420 <br /> Ft <br /> NON-REFUNDABLE PERMIT CALL, 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS !-'I" i\� 'i� {= � CITYlZIP I � i I I CROSS STREET Li;_!.I i'i,i L 14 { .,_ APN PARCEL SIZE <br /> OWNER NAME 1'' I�:I 1---� } i l°. <br /> ^ i PHONE <br /> @]j OWNER ADDRESS CITY/STATEIZIP <br /> CONTRACTOR ;ti PHONE <br /> CONTRACTORADDRESS 16.'_ -} I.1rIL`;f4.';`tI CITYISTATEl2]P_ir.:k: %1yii;�..1.�� <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE I <br /> F WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X y <br /> f l]� PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# 17'. <br /> = -�;- <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADD1TtON ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> i INSTALLATION WILL SERVE: ❑ RESIDENCE i❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: N UMBER OF EMPLOYEES: <br /> i ❑ SEPTIC TANK TYPE/MFG CAPACITY <br /> gal #OF COMPARTMENTS <br /> i ❑ CREASE TRAP TYPE/MFG CAFACiTY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES Q LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION A PROPERTY LINE ft <br /> FFF I ❑ MOUNDED WIDTH (t LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPLRTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH <br /> It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH fi DEPTH ft <br /> • DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LINE ft <br /> i O SEEPAGE PITS NUMBER WIDTH ft DF,PTH ft <br /> 1 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 /> ` ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> IYf� - -i-- MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTION-PLEASE CALL(2()9)953-7697 <br /> F I SIGNED (� �. l.f.,�-•L-�_-'` TITLE ."?:f„f.. 1`V 61(-0 I � DATE ��/6f h . <br /> i <br /> LOH I <br /> 1 14 <br /> 7 <br /> Y (` <br /> 1 ✓ I <br /> f'` ( ;' t f <br /> iLL- <br /> RAI <br /> }�1_ 41 — <br /> f <br /> ENS <br /> 1 N E T L <br /> '.�(� �' r H M <br /> TM <br /> DEPARTMENT <br /> N <br /> I <br /> DEPARTMENT USE gNLY <br /> { F Application Accepted By '.-�.-1--c- Date �'):!!�"" 13-' Area Employee ID# <br /> ]lTi 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 'Checldfil„� Amount Permit/ <br /> Code INFO B I"Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 1 2/2212 00 3 <br />