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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT �FjU <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"0 FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDA11 BLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> C17Y21P <br /> CROSS STREET '',1l APN�J� _ PARCELSIZE o <br /> icy <br /> OWNER NAME {�I � 4 A <br /> PHf)\k. <br /> OWNER ADDRESS CITY/STATF/LIP -"IQ�:t—CA <br /> CONTRACTOR <br /> :. <br /> fIPHont. <br /> CONTRACTOR ADDRESS <br /> CITY/STATFIZIP ll�Yl'(1 <br /> LICENSE ❑C42 C-36 OTHER NUMBER E%PIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X <br /> V <br /> ❑ PERC TEST # BUILDING PERMIT# — LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION O REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE 1� <br /> ❑ REPLACEMENT O DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: t� <br /> SEPTIC TANK TYpE/MFcptlP,l CAPACITY—VIM _ gal # �[ <br /> OF COMPARTMENTS�� <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY <br /> �C- <br /> gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL 6 0 R FOUNDATION R PROPERTY LME 5� <br /> it <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES J'� <br /> I <br /> �.� LENGTH OF LINES �v ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION _R PROPERTY LINE <br /> O FILTER BED WIDTHft <br /> ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> (3 MOUNDED WIDTH ft <br /> R LENOTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LME <br /> ❑ SUMPS WIDTHft <br /> ft LENGTH ft DEPTH <br /> E3 DISPOSAL PONDS WIDTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> R LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL 4 FOUNpATION R PROPERTY LINE <br /> SEEPAGE PITS NUMBER_ f R <br /> WIDTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION <br /> ft PROPERTY LME n <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORIN NCES,ST TE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> NI 1 UM 24 UR AD NCE NOTICE REQUIRED FOR INS ONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> -�ron(A T�u4� P � pArnp tr'% tl�. <br /> 64 <br /> t t <br /> i Q,IN <br /> -_� T E <br /> I�p w <br /> F-- <br /> 1-353,) <br /> --3 <br /> Application te Date ? � SPECIAL PERMIT <br /> Area <br /> Final do Date Employee l"/i'CT/p 7 <br /> Character <br /> o do of Soll to Dep of 3 Pt: ❑ SP ;,Approved by <br /> COMMENTS f- PIUSump Soil Character: <br /> ' <br /> PE SC Received Ghee Amount Permit/ <br /> Code INFO B Cash Remitted Date Invoice# Permit ID# <br /> / n' Service R nest# <br /> 42.02-001 �.rfe ✓0.7.�P//�.�+'�i�-t �xss �e�- +� <br /> 12222003 1-6 "� C —'-I�E9RftPEWATER PERMIT <br />