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23 - <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMINE® <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -31°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS v 3 1 CITY/ZIP �y O(.lC7w n.� LA <br /> K "1 <br /> CROSS STREET APN 1//9 /�© ,3 PARCEL SIZE / f <br /> v <br /> v <br /> { f � <br /> OWNER NAME �hN PHONE <br /> OWNER ADDRESS J ly Ao 6 CITY/STATE/ZIP _S f`3CiIC J�� C1, <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS G✓ CITY/STATE/ZIP J <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: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ill RRESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: / NUMBER OF EMPLOYEES: <br /> ® SEPTIC TANK TYPE/MFG ��/ CAPACITY / 2 V gal #OF COMPARTMENTS Z <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY p gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION l d ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> fd LEACH LINES ❑ LEACHING CHAMBERS #OF LINES Z LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL.... ft FOUNDATION ft PROPERTY LINE f 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 LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> '® SEEPAGE PITS NUMBER G_ WIDTH q .' ft DEPTH —_';_'j— ft <br /> DISTANCE TO NEAREST WELL J ft FOUNDATION j�Z� ft PROPERTY LINEt' ft <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 /> MINIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE C LL(209)953-7697 <br /> SIGNED TITLE�)�Z //.� c��U�� DATEA. <br /> e <br /> Iv <br /> Mnix <br /> - - - <br /> _41 4- _ 1 -1 <br /> -- - - - _- -- <br /> DEPARTMENT USE NLY <br /> Application Accepted e .Z Area ` Employee ID# W <br /> Final Inspection B Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dep of Ft: onPit/Sump oil Character: <br /> COMMENTS JM <br /> PE SC Received C Amount ate Permit/ Invoice# Permit ID# <br /> Code INFO ash Remitted Service Re uest# <br /> 33 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />