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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> LAN JOAQUIN COUNTI"ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3N"FL-STOCKTON CA 95202 - (209)468-3420 <br /> JON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES <br /> YEAR FROM DATE ISSUED <br /> OB ADDRESS �% / 4 r� C1111ZIP !( a `� I <br /> %f y^ <br /> (' <br /> CROSS STREET �1 /2/2 C gAPN 1 K J T "=l C' PARCEL SIIZJELi <br /> p <br /> PHONE <br /> )INNER NAME 't' i�.Cs L' f��r+ j � yy �' <br /> OWNER ADDRESS r I,sf ��� T- C I 1 ri i•i [ CITY/STATE/ZIP f. C' )'7 ( Cj <br /> 'ONTRACTOR s G /\f �-i/�( � C %i �i/O PHONE <br /> CONTRACTOR ADDRESS -k- b !s ' CITY/STATE/ZIP <br /> LICENSE ❑C-42 C-36 OTHER -3 NUMBER EXPIRATION DATE <br /> b.rVATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> ;YPEOFWORK: §� 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 /> p I <br /> '\ SEPTIC TANK TYPE/MFG_Ca*j c j'l i4-1 (F CAPACITY c? 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 /> r. <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 I'FC' ft FOUNDATION ft PROPERTY LINE ft <br /> 7 FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> V <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 R <br /> SEEPAGE PITSCZ% VIDTH _� t6 ft LENGTH ft DEPTH �� ft <br /> /DISTANCE TO NEAREST WELL /40 ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> bw STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE.CALL(209)953-7697 <br /> SIGNED x- J TITLE (,it / /''y' K3 DATE <br /> 0� <br /> 0 <br /> I � I <br /> J. <br /> � t— -T, w, <br /> w <br /> C A u <br /> O <br /> i <br /> E 0 <br /> Q o 7a ri 3 <br /> eo x <br /> S2 h 0 <br /> O <br /> (D N .OS Q <br /> 049 <br />