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ONSITE WA', LWATER TREATMENT SYS'A4 PERMIT / <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3k°FL-STOCKTON CA 95202 - (209)469-3420 <br /> NON-REFUNDABLE PERMIT rLCALL 209)x9,53-7697 FOR INSPECTIONS EXPIRES.1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7 d. :5Y. 27 CITY/ZIP y <br /> CROSS STREET APIV _ "�f.0�" �Cx PARCEL SIZE <br /> r OWNER NAME <br /> PHON <br /> OWNER ADDRESS D I CITY/STATE/ZIP 4t) C <br /> fluo <br /> CONTRACTOR ✓ PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBERi 5L EXPIRATION DATE 7 (] <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION#- W <br /> OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE �r <br /> ❑ REPLACEMENT ❑ DESTRUCTION V� <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LI VI NG UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> i ❑ SEPTIC TANK TYPE/MFG 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 /> IZA <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 /> ElFILTER 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 LME 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 WIDTH ft DEPTH ft <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 /> MINI UM 24 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �� <br /> i TITLE ��,VIL- r�RJ / 7ZDATE 40 C✓ <br /> 1 <br /> -F7 <br /> D <br /> 01 <br /> J <br /> 1 41 <br /> COMITY. <br /> V H N EN <br /> L <br /> DEPARTMENT US ONLY i l /T <br /> Application Acc ted By Date ro t� Area Employee lD#� f <br /> 7/(,�q <br /> 1 <br /> 1 Final Inspection B Date Q SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 F: Pit/Sump Soil Character: <br /> COMMENTS - / �?G D 8 �d�.:i / /✓ U <br /> PE SC Received ' <br /> Amount Date Permit/ <br /> Code INFO B Cash Remitted Service Re uest# Inv ire# Permi [ <br /> 42-02-001 <br /> 12122/2003 ONSITE WASTEWATER PERMIT <br /> '��j�l7 <br />