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ONSITE WAEWATER TREATMENT SYM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTh)OEPARTMENT 304 E WEBEk,VE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS E� VYtiY.TX�gP�IRE�S I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYIZIP Gl51Jt agnLon <br /> kyr� � <br /> CROSS STREET Lv b API O — 'To ERV9ft C po <br /> OWNER NAME <br /> V & <br /> OWNER ADDRESS P CITYISTATE/ZIP <br /> cLLAMCA �522�_l <br /> CONTRACTOR [J. ; bn PHONE - <br /> CONTRACTOR ADDRESSCITVI,STATEIZIP <br /> LICENSE :3 C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION:''Coordinates X Y <br /> ,® PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPEOFWORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ r 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 /> i ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> j DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> i <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE Ir <br /> ❑ DISPOSAL PONDS WIDTH R- LENGTH R DEPTH ft <br /> f ' <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 /> 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 /> IMU 24 H NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697-.; <br /> SIGNED TITLE DATE <br /> 3 � r <br /> jos <br /> j174vmoNME NT L <br /> EAT H D E.pAI. K.E <br /> � 5 <br /> FV <br /> i <br /> S <br /> DEPARTMENT USE.ON Y <br /> Application Accepte Date MY Employee]D# L5 S g 9 <br /> Final Inspection By Date 13 fj © SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 4 Ft: t Pit/Sump Soil Character: <br /> COMMENTS <br /> I <br /> PE SC Received Check#/ Amount Permit! <br /> Code INFO B as Remitted Date Service Request# Invoice# Permit ID# <br /> I <br /> + 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12122!2003 <br /> it <br />