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ONSITE WAS"'`WATER TREATMENT SYSTrM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D�_+RTMEN't , - - 304 E WEBER A.,_-3 FL-STOCKTON CA 95202 - (209)468-3420 <br /> y NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS. EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> , j1 <br /> � <br /> JOB ADDRESS 3s"s"� ee _ CITYIZIP <br /> C <br /> CROSS STREET APN PARCEL SIZE /�itG C <br /> ISI `, <br /> OWNER NAME U�3 PHONE x ri <br /> OWNER ADDRESS CITYISTATEIZIP ILL UU1 <br /> CONTRACTOR.. LG!��,�YJ! PHONE <br /> �T J / <br /> CONTRACTOR ADDRESS C ITYIlSTTATEIZI /P_ arL�.l <br /> LICENSE a.0-42 ❑C-36 OTHER NUMBER UT S EXPIRATION DATE ) <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y �\ <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ "NE&INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT Q DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 3 NUMBEROF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG_jl�9jt L CAPACITY J gat #OFCOMPARTMENTS :2 <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL Ss, R FOUNDATION Sa ft PROPERTY LINE <br /> 1 ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> A .�,/ <br /> LEACH LINES LEACHING CHAMBERS / Q �'7 #OF LINES LENGTH OF LINES /C+� - ft <br /> DISTANCE TO NEAREST WELL ��ft FOUNDATION ft PROPERTY LINE 1520 ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> t 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 R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH - ft LENGTH ft DEPTH <br /> 1] DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft 'LENGTH ft DEPTH_ It <br /> i <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> "I� ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH ft <br /> =I� DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> i <br /> I� I HEREBY CERTIFY THAT 1 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 /> INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> `I SIGNED TITLE DATE I�d? <br /> v c <br /> I <br /> Il <br /> YFAE- <br /> J <br /> E <br /> r <br /> 'i <br /> 08 1C <br /> id ENVI RON MEN AL c+, TN IVIS C1 <br /> ju k <br /> fl� <br /> e <br /> _yy DEPARTMENT USE <br /> Application Accepted By Date Q Z Area & 1 Employee ID# t{r <br /> Final Inspection By Date /0/-?"/� ❑ SPECIAL PERMIT-Approved by Li <br /> i Character of Soil to D th of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS o Z -3 Co G <br /> PE Sc Received Che I Amount Date Permit/ Invoice# Permit 1D# <br /> Code INFO B Cash Remitted Service Request# <br /> 42-01-001 <br /> ONSITE WASTEWATER PERMIT <br /> �,� 12!2102 <br />