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ONSITE WASTEWATEF UAT MEM'PERMIT <br /> �N JOAQUIN CQUNTV ENVIRONMENTAL HEALTH DEPARTMENT %"/ 304E WEBER AVE-3"FL-STOCKTON CA 95202 .M/i9)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 'iBADDREss GP 7C TGI iE d CIT,/ZIP 0 1 H <br /> 103E STREETrTIAV 1lYAA 1I�G/' ppN �(o'�-�ILG'C9- PARCEL SIZE I. --)L, <br /> OWNER NAME -IIY1'0 ro,lv1Pal'\LA PHONE�1�/' f A q �f,4 <br /> A'NERADDRESS `�./�G. e 2 11 ` / CITY/STATE/ZIP Fra l )-LC ` A ?1 _12-4- <br /> ]NTRAROR IV{C I A l l S 1 ' ) lC . PHONE <br /> CONTRACPORADDREES 'I,; _ • A, , q CITY/STATFJZIP 1 <br /> CENSE 13 C42 13 C-36 OTHER NUMBER EXPIRATION DATE J <br /> CATER TABLE DEPTH: ft GEOGRAPHICALINFORMATION: Coordinates X y <br /> PERCTEST # BUILDING PERMIT# LAND USE.APPLICATION# <br /> TYPE OF WORK: ❑ NEWINSTALLATION ❑ REPAIWADDRION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> r ❑ REPLACEMENT ❑ DenRUCTION <br /> .STALLATION WILL SERVE: ❑ RESIDENCES ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> GREASE TRAP TYPE/MFG CAPACHT gal #OF COMPARTMENTS <br /> U PKG TX PLANT DISTANCE TO NEAREBE: WELL ft FouNDATION ft PROPERTY Lme <br /> ❑ LIFT STATION SIM TYPEOFPUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBER$ #oELINES LENGTHOFLNES R <br /> DISTANCETONEAREST WELL R FOUNDATION ft PROPERTY LINE It <br /> ❑ FILTER BED WIDTH ft LENGTH - ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> MOUNDED W. ft LENGTH ft DBPTN R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTYLINE ft <br /> ❑ SUMPS WmrH A LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> _ DISPOSAL PONDS WmTH It LENGTH ft DEPTH It <br /> DISTANrew NEAREST WELL IN FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> 40 THEREBY 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 /> MINIM UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> TITLE �/ /� � T DATE <br /> f <br /> J <br /> i <br /> V 1 <br /> T <br /> TH <br /> I <br /> DEPARTMEN�T�SN^V� A. <br /> ' Employ«IDp <br /> Application A¢epkd By --- -"G_ pap <br /> ) V <br /> SM Inspection By Dao ❑ SPECIAL PERMIT-AppmvWby � <br /> iarocter of Soil loDepth R(3 Ft PIUSUMP Sail Chmacmr: <br /> COMMENTS <br /> YMPESC R"wol ChsMH A. P.Wtl <br /> Code INFO B Cah Remd= Dale ServkeR vqt# Involsx# Permit lD# <br /> 2zL l1 Uf 3 asTs pxno413(-1 <br /> �DJ-BOT ONSITE WASTEWATER PERMIT <br /> I L13I3CD] � <br />