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_� it `�0 <br /> ONSITE WAST}�,�.rATER TREATMENT SYSTEM: PERMIT ,29z) /4- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -k"�FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPEC IONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> I JOB ADDRESS. CITY/ZIP TA a:2 2i 4- ) <br /> CROSS STREET _ APNLJ` � r PARCEL SIZE_ 1 I J r T , <br /> OWNER NAME: PHONE <br /> 1 <br /> OWNF.RADDRESS /V CITY/STATEIZIP/� fY1 .T'C C76 :�Yz- - <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE ❑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 /> TYPE OF WORK: ❑ I NEW INSTALLATION I ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION VVV <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 /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft j <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft i <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CER THAT I HAVE PREPARED THI PPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY E <br /> ORDINANCES,STAT AWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. t <br /> i <br /> MINIM O A C NOTIC FOR iNSPECTJONS-PLEAS LL(209)953-7697 <br /> SIGNED � TITLE DATE <br /> r A •. � <br /> _ - _ <br /> *00 <br /> -- - - - I-- <br /> 7 <br /> _ O I <br /> - _ - - � i <br /> PARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# 155 -12<,16 <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> 7T <br /> PE Sc Received Check# Amount Permit/ <br /> Cade INFo B Cash Remitted Date Ir fService Request <br /> # Invoice# Pe <br /> ZZZ. `4 <br /> 42.02-00E 9� r i-- ON WAST- AJR(%,�IT <br />