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ONSITE WAS' WATER TREATMENT SYST I PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DMEPARTMENT 304 E WEBER Ash -FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7, 3 S-qu7? , ingki AVaA/ur— CITY/ZIP <br /> CROSS STREET L.� WN fG /tr:Y1"� APN -Q 3 PARCEL SIZE <br /> v <br /> v <br /> OWNER NAME NEnl21/ �/.�N �/al2 Ems/ PHONE 9 3,./3 -Q�2/,/ y <br /> OWNER ADDRESS / � �. ST�(,�LA ✓E/V 1�.1� CITY/STATE/ZIP S7U&7 A <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: n./ S ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # o�Z BUILDING PERMIT# LAND USE APPLICATION Y0A- O <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <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 ft <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 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft �• <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> cN <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 NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> c <br /> 1 HEREBY CE T FY THAT 1 HAA PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY (h <br /> -,7 NANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIS H ADV NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE ejl ODATE <br /> ! 0 <br /> p N� <br /> DEPARTMENT US ONI Y <br /> Application Accepte Date <br /> �' ( Qc Area Employee ID# <br /> Final Inspection B, <br /> Date `���r�� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depthlpf 3 Ft: it/Sump Soil Character: <br /> COMMENTS <br /> � <br /> PE SC Received Check# Amount Permit/ Invoice# Permit ID# <br /> Date Service Re uest# <br /> Code INFO B Cash Remitted <br /> 12-2z S 2.i � /�G�.0 <br /> ONSITE WASTEWATER PERMIT <br /> 42-02 <br /> 12/22/220 0033 <br />