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ONSITE WASTE"WATER TREATMENT SYSTr PERMITS t> <br /> SAN JOAQUIN TY ENVIRONMENTAL HEALTH DE. .tTMENT 304 E WEBER A,,_.,-3"°FL-STOCKTON CA 95202 - (209)46$-3420 <br /> NON-REF LE PERMIT CALL(209}953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 32 Q <br /> JOB ADDRESS <br /> CIT YIZIP tyn <br /> CROSS STREET D!-N APN �'f "" .� ` .— PARCEL SIZE p <br /> i PHONE `T `T <br /> OWNER NAME <br /> ell <br /> OWNERADDRESS _ 1 y L� _ _ CITYISTATEIZ[P <br /> W�=-;dJ,���s+M-1----LTJ - <br /> PHONE <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> tCie, <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> # .f <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION <br /> TYPE OF WORK: fip NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNEDIALTERNATIVE �l <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: W RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> { NUMBER OF LIVING UNITS: SO NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: �J <br /> f� SEPTIC TANK TYPE/MFG �/ CAPACITY gal #OF COMPARTMENTS <br /> ❑ CREASE TRAP TYPFJMFG CAPACITY gal #OF COMPARTMENTS <br /> i ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ' 7r / ft FOUNDATION /V ft PROPERTY LINE f/d ,ft p <br /> ❑ LIFT STATION Slz€ TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) y <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES ^ LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELLG]LLL _ft FOUNDATION � ft PROPERTY LINE IJ ft <br /> y ❑ FILTER BED WIDTH Il LENGTH ft DEPTH ft <br /> 1 DISTANCE TO NEAREST WELL ft 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 /> M SUMPS WIDTH ' ft LENGTH / ' ft DEPTH r ft <br /> DISTANCE TO NEAREST WELL 12 o FOUNDATION }- t� PROPERTY LINE h( 1 , ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH A <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> F ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MI ' MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 f <br /> SIGNED TITLE _�%!Yr1/l�� r DATE <br /> 9 <br /> f r 1 <br /> i <br /> (! DEPARTMENT USE N! <br /> Application Accepted By Date t° Area �J� h Employee lD# j� <br /> Final inspection By r Date Z ` [3 SPECIAL PERMIT-Approved by <br /> Character of Soil to De 04of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS ! i <br /> ef4 <br /> PE SC."', Received heck Amount Date Permit/ Invoice# Permit ID# <br /> Code IN o By ash Remitted Service Request# <br /> 42-01-001 ONSITE WASTEWATER PERMIT <br /> 1212!02 <br />