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i r <br /> ONSITE WA� 'WATER TREATMENT SYS ,,M PERI A ' <br />' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NOIR'-REFUNDABLE PERMIT CALL 249 953-7697 FOR INSPECTION'S EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS ►Qcpta3 _ a,,, 3B CITY/ZIP ���'SJ? <br /> r <br /> CROSS STREET ��- APN 063 ;�,, PARCEL SIZE 2L C <br /> nom- d <br /> OWNER NAME PHONE <br /> OWNER ADDRESS ►�Z�'L� �L��1��i�. l CITY/STATEIZIP [VGCC�►'�, �+ 4 SZ1'L <br />€ CONTRACTOR ` "�t_Q� •� 'a.:44L_ PHONE Aw.'epya s <br /> CONTRACTOR ADDRESS In l4 vKl p CITY/STATE/ZIP -TD . ais%^ ' <br /> LICENSE ❑C42 ❑C-36 OTHER C_-2-k NUMBERJr, \ EXPIRATION DATE r: <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: (3 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 TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP .TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCETO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ! <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES <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 R 1 i <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ftp <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTHft :LENGTH fi °DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tZ <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft CIV <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> i <br /> I HEREBY CERTIFY THAT 1 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 INSPECTIONS-PLEA9^4qf!� <br /> ALL(209)953-7697 <br /> SIGNEDy. ..t-�`#.. r Y _ y�_ TITLEI�►1Q�+�►4— DATE <br /> +' <br /> r <br /> r <br /> 1 <br /> I <br /> I <br /> go V17-0 <br /> ftb ULD <br /> N E9- , <br /> H E A <br /> PE_ r <br /> ____ ._. DEPARTMENT USE ONLY f <br /> . <br /> Application Accept Date � (� Area Employee <br /> Final Inspection B ❑ SPECIAL PERMIT-Approved by , <br /> Character of Soil to of 3 Pit/Sump Soil Character: <br /> COMMENTS ,int _ a��.lOL� �J F � 21E °vim <br /> PE SC Received C ec Amount Date Permit/ Ine# Permit lD# <br /> Code INFO By Cash Remitted Service Re uest# c <br /> 42--- EA) T 5 G <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />