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/Z " 7& ONSITE WAS"WATER TREATMENT SYSTT`4 PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L%w,RTMENT 304 E WEBER A,., 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS r, CITYIZIP C� �l <br /> 1f ^�L `� p <br /> CROSS STREET QL c- _1 . APN q � V O PARCEL SIZE I G. 2l <br /> OWNER NAME UCQA✓(Y�] 4rC:CJ G�\ - - -- PHONE 10 G-I/j rI� ^� <br /> OWNER ADDRESS /}�JrQ �t�j't�.Y'1 _ �CL CITYISTATE/ZIP� i CA q S-32)6 <br /> CONTRACTOR u �!2'iG'� ��r �'�I�[•�'� {PHONE/ - — 1 <br /> CONTRACTOR ADDRESS 25 2 F /MF 1 4 -Si, CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER C-57 NUMBER y6�72 2 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL.INFORMATION: Coordinates X F Y <br /> PERC TEST(S) NUMBER_ -3 LAND USE APPLICATION# PA-o,4 -77 _ <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT Q DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ 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 CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES fi <br /> DISTANCE TO NEAREST WELL ft FOUNDATION tt PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ti <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH f7 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQLIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIr2jUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECT( o`'IIO`NS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Z�e,- 1 �1/ls,f�e�C DATE D� to'f <br /> i:1 2 3 2`3 .! -I y <br /> t D v" <br /> r <br /> + <br /> RP W <br /> N P R M T <br /> DEPARTMENT IfNEO LY <br /> Application Accepted By Date �� Area Employee 1D# / <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#! Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO BY Remitted Service Re uest# <br /> l�I1S Z9 <br /> 42-01-001 <br /> 12%2102 ONSITE WASTEWATER PERMIT <br />