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'lam S-rb �Tqpr- I cf�Ar-cN <br /> ONSITE WAf EWATER TREATMENT SY� ^v1�VI PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTFbW rPARTMENT 304 E WEBER—(E -3"°FL-STOCKTON CA 95202 - (209)465-3420 <br /> NON-REFUNDABLE PERMIT ,C[ALL,(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS S /�.1 U NOLrl � /� p�CITY/ZIIP� �) CTC/X.) <br /> CROSS STREET NrT�{I`TEQ- L� APN V a 7 -OLL-"`1.Y PARCEL SIZE <br /> p ��o <br /> OWNER NAME S T�CC�-�'L7�J{ O �TT.ST �'-F{LG-LIQ-G/-/ Y—S CIOb(_ PHONE YA' <br /> OWNER ADDRESSr S�� j CITY/STATE/ZIP <br /> KLCONTRACTOR /Y L EI N FF- LJ�l� yb0 C, . J PHONE <br /> CONTRACTOR ADDRESS �C]4� E , (My/?7-LE- CITY/STATE/ZIP e,7Wk N /M2105- <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE ( (t <br /> WATER TABLE DEPTH: ft GEGGRAPHICALINFORMATION: Coordinates X Y <br /> ixPERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEWINSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE G <br /> ❑ REPLACEMENT ❑ 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 /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE IT <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft ti <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 A <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE IT <br /> I HEREBY TIFV THAT 1 HAVE PREPA ED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE W ITH SAN JOAQU IN COUNTY ORDINANCES, <br /> ST ELAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> e M MU 4 N R ADVANCE NOTICE REQUIRED FOR INS/P�EdCT�IONS-PLEASE CALL(209)953-7697 // <br /> SIGNED r TITLE N//4rC 'tN��NEE/L_ DATE /1{• <br /> we. <br /> V Lt <br /> I - <br /> �- <br /> EN IR N E <br /> HIZAL LA <br /> 0� <br /> DEPARTMENT USE ONLY <br /> Application Accepte - Date 1 /('40!v- Area �-� Employee ID# s9 <br /> Final InspectionV�rl - Date e— ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to [h of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By as Remitted Service Request# <br /> 4{2.z 521 93 00 l /o D 5L-G,(L-, <br /> 42-01-001 <br /> 122/02 ONSITE WASTEWATER PERMIT <br />