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ONSITE WAS-`WWATER TREATMENT SYS M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH. ARTMENT 304E WEBER, -3",;FL-STOCKTON CA 95202 - (209)468-3420 <br /> 1 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP loI' <br /> d /052T7 <br /> APN r_ D ir !�D-3 .9 PARCEL SIZE O-CJ a <br /> CROSS STREET .[/ 1b C r 0 <br /> OWNER NAME V r A L10 lei to 0. PHONE y <br /> OWNER ADDRESS / iYy� LlJ �J WW��CITYISTATE/ZIP <br /> CONTRACTOR � rX�5I D� L. -- PHONE <br /> CONTRACTOR ADDRESS /IYI r/(7(rI J(I,(/ - CITY-IISTATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER (2 14 L EXPIRATION DATE 3CJ G GO <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y V <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION EIREPAIRIADDIT ON ❑ flyR[1ESIGPUtreNVIVF <br /> ❑ REPLACEMENT DESTRUCTION m <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER Y' <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:, NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG {I1 vLBcr r1 CAPACITY Sal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST; WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP L3 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH fZ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION f3 PROPERTY LINE ft 000 <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 DEPTH_ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH <br /> ft, <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE tN ACCORDANCE WITH SAN JOAQUIN COUNTY'OR6INANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> M2 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> i <br /> SIGNS /� �a/L� TITLE V DATE <br /> �c ¢ a <br /> ARFa4 <br /> Am <br /> 77, <br /> S <br /> I <br /> 17- <br /> f ►� PSP ' ;� I " ; <br /> ., rf <br /> Application Accepte y - Date 4 Area Employee IID#- F /q� <br /> Final Inspection Date /��� ❑ SPECIAL PERMIT-Approved by <br /> Cbaracter of So th 3 Ft: P,'t1SU p Soil Char <br /> COMMENTS <br /> PE SC Received / Amount Date Permit/ Invoice# Permit ID# <br /> Cade INFO B as Remitted Service Request# <br /> 2i 9 <br /> 42-01-001 <br /> 12/2102 ONSITE WASTEWATER PERMIT <br />