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ONSITE WASTEWAT�1REATMENT SYSTEM PERMIT <br /> USAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-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 /> JOBADDRESs <br /> j I I �`� 4 I CITY/ZIP <br /> ! y <br /> CROSS STREET r. ,( ��- �A {• 1 -� (", �r (. A ) rn <br /> ! ! �,,"rl..s.T�.' a FiPN '!e-j Y-.. PARCEL SIZE'?f 'TSI . o <br /> 7OWNER NAME '7 `I� I,+ ;-+., I%_�4 t:.l -} rE m - <br /> - PHONE <br /> OWNERADDRESS , p CITY/STATE/ZIP <br /> J1 r <br /> CONTRACTOR PHONE ./�! 4i <br /> CONTRACTOR ADDRESS - - <br /> 'I CITY/STATE/ZIP - <br /> I <br /> 'ICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE - <br /> NATER TABLE DEPTH: <br /> R GEOGRAPHICAL INPGRMATIGN: Coordinates X Y ! IJ <br /> ❑, PERC TEST # !r BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: Li "NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT <br /> ❑ DESTRUCTION <br /> �INSTALLATION WILL SERVE: ❑ RESIDENCES ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES r <br /> Q SEPTIC TANK TYPEIMFG 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 <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> i <br /> `] LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> L3 FILTER BED WIDTH ft LENGTH R DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft �w <br /> MOUNDED WIDTH R LENGTH ft DEPTH R ' <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft - <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH tt <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R -.-� <br /> ,..I DISPOSAL PONDS WIDTHt <br /> R LENGTH R DEPTH ft' <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SEEPAGE PITS NUMBER WmTH ft DEPTH <br /> DISTANCE TO NEAREST WELL' ft FOUNDATION ft PROPERTY LINE ft n, <br /> w• 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> GNED TITLEi --? <br /> DATE j <br /> i <br /> 1 _ I r5 j <br /> ` FT II i.l <br /> i I <br /> �.ID <br /> A 4 A UI 4 Z�—u TY <br /> j ) NT <br /> I ) <br /> I � , <br /> j - <br /> i I � <br /> r I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By y. `T.Date � I", i'si Area i J (; Employee ID# I <br /> t._ .. 1 <br /> at Inspection By — _ Date ❑ SPECIAL PERMIT-Approved by <br /> aaairacter of Soil to Depth of Ft: PiUSump Soil Character: <br /> COMMENTS <br /> N-VE SC Received Check#/ Amount Permit/ <br /> Code INFO B Cash Remdtted Date Service Request# Invoice# PermitID# <br /> 2/222/2201003 <br /> 128ONSITE WASTEWATER PERMIT <br /> 1 ' <br />