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ONSITE WASTEWATER—TREATMENT_ SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 104`E-WfB9R-AvF-TFL-STUCKTON CA 95202 -(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1i[.� <br /> JOB ADDRESS iaC. dlz CITY/ZIP '1is (`r I .r / 1 q <br /> CROSS STREET1^,,t' C>tI F e AAPN C.,�S �a!✓' C PARCEL SIZE <br /> OWNER NAME Ch Y.Y l u L1 1 Mnbhr Hcm C. f�)t Imo. PHONE <br /> OWNER ADDRESS <br /> CITY/STATE/ZIP <br /> CONTRACTOR I I r tc PHONE 'C" - 7 <br /> CONTRACTOR ADDRESS -3 I ual\ CITY/STATE/ZIP `7 <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ 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 /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS Q <br /> ❑ PKGTXPLANT DISTANCE TO NEAREST: WELL r ft FOUNDATION ft PROPERTY LME ft(\ <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) IRS, <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES it P-- <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ FILTER HED WIDTH it LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ii <br /> ❑ MOUNDED WIDTH ft LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH it DEPTH R <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LME it <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 /> AINIIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> —PLEASE CALL(209)953.7697 l <br /> SIGNED /bl 1/," Ao/\ TITLE (_4/C'�Gl f S DATE <br /> All <br /> L <br /> c <br /> 6 <br /> T <br /> p UN <br /> E T E <br /> F'TTT--##1,#j#--+1 1 ----#-- <br /> DEPARTMENT US ONL <br /> Applicetlon Accepted By Date '.1 y D Area / Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT•Approved by /9 <br /> Character of So31 to Depth o13 Ft: Pit/Sump Sall Character: <br /> COMMENTS cxr,41 E<, {W!3 � �„tl � tu1ll o,-e a a� <br /> PE SC Received Check# Amount Permlt/ <br /> Code INFO B ash Remitted Date Service Re uest# Invoice# Permit ID# <br /> �12.az s21 2L /S.9ScS' cU <br /> 43 0 <br /> .- 42.02.001 ONSITE WASTEWATE R PERMIT <br /> 12/2212003 <br /> g <br />