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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT ,Iul OU t ars r' <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE - 3'° FL- STOCKTON CA 95202 - (209) 468-3420 <br />NON-RFFIINOARI.F PERMIT CALL (209) 953-76971 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 3;LICE <br />CY/"LIP <br />5' S IT J- <br />CROSSSTREET tS <br />^ <br />t�Y APs�/N / �S�DD LS7 ARCEL SIZE <br />"" ' <br />OWNER NAME—J_6s1/-off <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR <br />/ <br />1..--- PHONE <br />CONTRACTOR ADDRESS <br />CITY/STATEPLIP <br />LICENSE ❑ C42 <br />❑ C-36 OTHER NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: CDordleates X Y <br />❑ PERCTEST # <br />BUILDINGPERMIT# O LAND USE APPLICATION# <br />TYPE OF WORK: <br />NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: C� RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: V NUMBER OF EMPLOYEES: <br />JX, SEPTIC TANK <br />TYPFJ MFG. CAPACITY ( [� n gal # OFCOMPARTMENTS <br />Qy, <br />❑ CREASE TRAP <br />TYPE/MFG CAPACITY gel #OF COMPARTMENTS I C) <br />`1 <br />d <br />❑ PKC TX PLANT <br />DISTANCETONEARESr: WELL ft FOUNDATION ft PROPERTY LINE ft <br />L) <br />❑ LIFT STATION <br />SIzE TYPE OF PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />EACHING CHAMBERS rJ+'t t ( !' # OF LINES —1-0— LENGTH OF LINES Z ft <br />( <br />DISTANCE TO NEAREST WELL O R FOUNDATION it PROPERTY LME <br />❑ FILTER BED <br />WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION f2 PROPERTY LINE R <br />O <br />❑ MOUNDED <br />WIDTH it LENGTH ft DEPTH ft <br />DISTANCETO NEAREST WELL R FOUNDATION ft PROPERTY LME ft <br />3{I, SUMPS <br />WIDTH 2,_ It LENGTH Zi ( fr DEPTH t ft <br />C_ <br />DISTANCE TO NEAREST WELL 1,9:Zo ft FOUNDATION 1 0 R PROPERTY LINE Zi R <br />❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br />❑ SEEPAGE PITS <br />NUMBER WIDTH it DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LME ft <br />I 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 />MI MUM 24 HOUR ADVANCE NOTICE REQUI— IRINSPECT CALL(209)953-7697 <br />SIGNED� <br />'ITLE1`4 0 0 0 of aa& DATE / <br />/ <br />l <br />o <br />� <br />3a' <br />la' <br />i <br />D A <br />_. l <br />Application Accepted By Date t Area v Employee IDN <br />Final Inspection By <br />Date /_ 13SPECIAL PERMIT - Approved by <br />Character of SDI] to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />/2 `7-oS S Wn --- $t? f i�O`� V,( lbtin w# -is L? n+ ch e I <br />vt <br />1 <br />PE SC <br />Received Chet Amount Date Permit/ invoice # Permit ID# <br />Code INFO <br />B Cash Remitted Service Request # <br />4 <br />42-02-001 <br />ONSITE WASTEWATER PERMIT <br />1 212 2120 03 <br />