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1 <br /> ONSITE WA 'EWATER TREATMENT SY1, M PER rAN�VED �� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"u FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES i YEAR FROM DATE ISSUED <br /> �btp3 avJ 3s CITYIZIP q <br /> JOB ADDRESS I i <br /> r I 2 2r- <br /> CROSS STREET - APN 013 , 7 PARCEL SIZE { <br /> OWNER NAME L�F�"+ SfJ� �"�37 _ ._ PHONE <br /> OWNER ADDRESS �ZA'L. li- .ii� !� CITY/STATEIZIP �• 5;�1 ' <br /> �� A ! <br /> CONTRACTOR �+^` "^"� •� �'i`- PHONE Alli.(.-6019S <br /> CONTRACTOR ADDRESS CITYISTATEIZIP 'TD ZpS <br /> LICENSE ❑C42 L1 C-36 OTHER h•�1 NUMBER % EXPIRATION DATE t! <br /> WATER TABLE DEPTH; ft 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 d— DESTRUCTION <br /> INSTALLATION WILL SERVE: © RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> I <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> C <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft. LENGTH ft DEPTH, ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl . <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NumsER WIDTH ft DEPTH ft "G <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR <br /> � INSPECTIONS-PLEASE .7697 <br /> —SIGNED TITLESP^:a4e� T <br /> DATE .2-11-Le <br /> rI LI <br /> op kyMET <br /> go <br /> N <br /> T <br /> 1H H E A <br /> r J <br /> DEPARTMENT USE ONLY <br /> Application Accept Date Z Area Employee IN <br /> Final InspectionB .a_ .c rs+ kbate ��/�t�' 1 11SPECIAL PERMIT-Approved by <br /> Character of Soil to of 3 Ft: Pit/SumpSoil Character: <br /> COMMENTS r Z' ��CD( I n/ cS ll JO `rd4l c 2 ��� I M <br /> PE Sc Received C ec Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Re uest# [ e# Permit ID# <br /> 42a 0 7s ,s'i 72-, no v LA) <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />