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ONSITE WASTEWATER TREATMENT SYSTEM PE <br />FXOSANJOAQUIN COUNTY EWMI <br /> NVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3 R FL-STOCKTON C (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I ?9 1 d- Q A c; K ^ �G t_ CITY/ZIP <br /> ,I7tZ) } i <br /> CROSS STREET � �r L,+ r� <br /> APN _1 !2 Q tv PARCEL SIZE 5 4'C <br /> OWNER NAME <br /> PHONE y <br /> OWNER ADDRESS r C) \p CITY/STATE/ZIP �zo <br /> CONTRACTOR <br /> AJ � <br /> PHONE <br /> CONTRACTOR ADDRESS <br /> CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER UM ER <br /> EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATIOrdimite, X <br /> Y r <br /> FERC TEST # �_ BUILDING PERMIT# LAND USE APPLICATION# (1)4—j(}(_0 <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIWADDITION <br /> ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL <br /> ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br /> NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY <br /> gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY <br /> gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION <br /> ft PROPERTY LINE ft <br /> L3 LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES <br /> LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ FILTER BED WIDTHft <br /> ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> L3MOUNDED WIDTH ft <br /> ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> L1 sumps WIDTH ft <br /> ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE <br /> Ll DISPOSAL PONDS WIDTH ft <br /> ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SEEPAGE PITS NUMBERft <br /> WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> 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 /> MINIMU 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS_PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE DATE Z• v -� <br /> L <br /> m <br /> V�Z- /J o/eosi •u./ =:v �.tot�' Z-'d iV <br /> W b M1 <br /> I <br /> M1 <br /> B 05 <br /> uNV <br /> - - - A E AL <br /> DEPARTMENT UfSEPNLV <br /> Application Accepted By l.l./ Date �/ �[vim' <br /> Area �24 Employee ID# t+L/ <br /> Final Inspection By Date ry ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De of 3 <br /> �p Soil Character: <br /> COMMENTS <br /> PE SC Received eck#/ Amount Permit/ <br /> Code INFO B Cash Remitted Date <br /> Invoice# ~ <br /> Service Re nest# Per ID# <br /> 42-02-001 <br /> 12/22/2003 / J ONSITE WASTEWATER PERMIT <br />