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ONSITE WA'-"EWATER TREATMENT SY �,M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH'ti"ePAR'fMENT 304 E WEBER 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> -:.v'E - <br /> Ns EXPIRES 1 YEAR FROM DATE ISSUED <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR iNSPECTIOi <br /> Y � <br /> CITYIZIP I' <br /> JOB ADDRESS <br /> r APN PARCEL SIZE S d <br /> CROSS STREET <br /> / `/'��.. ..J�YSJ �� PHONE Yn•' . <br /> 34 <br /> OWNER NAME �r <br /> ��+� CITY/STATEIZIP 7 <br /> OWNER ADDRESS <br /> a U y+ dPHONE c <br /> CONTRACTOR (V Jr J <br /> CONTRACTOR ADDRESS <br /> 4 F <br /> CIT Y1STd TEIZIP11, <br /> � " <br /> NUMBER EXPIRATION DATE <br /> LICENSE ❑C-42 ❑C-36 OTHER <br /> WATER TABLE DEPTH:—, "~ ��- — <br /> ft GEOGRAPHICAL INFORMATION; Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# IyJ <br /> TYPE OF WORK: CI NEW INSTALLATION <br /> ❑ REPAIRIADDIT[ON ❑ ENGINEER DESIGNED IALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: (UMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ CREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft a - <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 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 LINE 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 /> RDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINI HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> SIGNED TITLE IJ DATE " "-C <br /> 40. <br /> AN Ouf <br /> 'plan ME <br /> N A <br /> LTa P R <br /> yj <br /> Ar <br /> v <br /> DEPARTMENT US O LY �" S <br /> Application Accepted By Date ®C•"" Area Employee IDA <br /> Final Inspection By NC/`T/ Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to DeAh of 3 Ft: PLUSumCharacter: <br /> COMMENTS ✓c�'� <br /> PE SC Received eck# Amount Date Permit/ Invoice# Permit IDA <br /> Code INFO -By AS .Remitted Service Request# <br /> q Z.zz_ sir � .�� 35R cam B2 55 7 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />