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ivy SCS `s <br /> ONSITE WA%.EWATER TREATMENT W4% M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3`"FL-STOCKTON CA 9$202 - (209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Q s1 CITY/ZIP 'y L4 <br /> m <br /> CROSSSTREET ON C5 APN D D— <br /> PARCEL SIZE QGi✓/ <br /> o <br /> OWNER NAME <br /> =`�y LUGeln CS PHONE s <br /> 7- <br /> OWNER <br /> OWNER ADDRESS CITY/STATE/ZIP --7 <br /> CONTRACTOR PHONE -3-761 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERCTEST # BUILDINGPERMIT# LAND USE APPLICATION# <br /> TYP OFWORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ 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 0 <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ FILTER BED WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL fl FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH It <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> 1 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 /> MINIMU 4HOU TICE REQUIRED FOR INS CALL CALL(209)953.7697 c/ J / ` <br /> SIGNED TITLE T/C G 'LQ DATE /%/�6 <br /> V <br /> ILIN <br /> A J <br /> VR M EN A <br /> TrANT E <br />