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9 <br /> ONSITE WA EWATER TREATME ".-h 9ERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT ppCALL(209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> LO °Q 4 �,•..i rD rQ CITY/ZIP L <br /> CROSS STREET �T -�l7 APN 0A_ ARCEL SIZE <br /> OWNER NAME ��d�ni 'S TI)r o�.. ��h�G _ PHONE <br /> OWNER ADDRESS CITYISTATE/ZIP j <br /> CONTRACTOR PHONE LO <br /> CONTRACTOR ADDRESS. CITYISTATEIZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # 5 BUILDING PERMIT# LAND USE APPLICATION# d 5 O 0 7a <br /> TYPE OF WORK: ❑ NEW INSTALLATION Cl REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT i ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑. SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ CREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION R -PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) CID <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft 4 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH t2 LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft, <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH - ft DEPTH - R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PON_DS--,WIDTH ft LENGTH R•. DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R 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 INSPECTIONS—PLEASE CALL,((22009))9953-7697 1 <br /> SIGNED ! TITLE ��..� f �, �e,n lDATE (O <br /> 1 <br /> 71, <br /> , v <br /> le <br /> 1 <br /> .0 <br /> J <br /> S <br /> -= - -- — <br /> DEPARTMENT-Us - N11'_-- - t <br /> Application Accepted By Date f U� Area Employee ID# <br /> Final inspection By Date 13 SPECIAL PERMIT-Approved by <br /> Character of Soil to th of 3 Ft: PitlS mp foil Character: <br /> C MMENTS ��/OS <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B ash Remitted Date Service Request# <br /> Uma -rte c <br /> 42-02-001 f V ��� �� ' ASTEWATER PERMIT <br /> � a�. / <br /> 1212212003" <br />