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, a <a <br /> ONSITE W EWATER TREATMENT S� : SEM PERMIT117 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3—FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABkLEAERjjIT CALL 953- 9'7 FOR INSPECTIONS EXPIRES I'YEAR FROM DATE ISSUED <br /> JOB ADDRESS ITY12'IP <br /> INC <br /> 9 y <br /> CROSS STREET AgnW __ APN PARCEL SIZE p <br /> OWNER NAME PHONE <br /> OWNER ADDRESS - - <br /> CITYISTATEIZIP _ <br /> ' \ sr-k <br /> CONTRACTOR -- ✓ IRWS I� `—A PHONE ` <br /> CONTRACTOR ADDRESSCITYISTATFJZIP - <br /> 1 <br /> LICENSE C-42 ©C-36 OTHER NUMBER EXPIRATION DATE <br /> �rx, ;,�WATER ITA�LE DEPTH: ft GEOGRAPHICAL INFORMATION; Coordinat¢S X Y j <br /> s' '�� �P,ERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> . Itr,.t$"TYPIIOFWORK: ❑ NEW INSTALLATION REPAIRIADDITION ❑ ENGINEERDES{CNEDIALTERNATIVE <br /> 0 REPLACEMENT © DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: _ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFg5 k-� CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL 200 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> } <br /> i <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft q f <br /> FILTER BED WIDTH - 20 ft LE GT /ftp DEPTH -- ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it ft PROPERTY LINE "� R <br /> ❑" MOUNDED WIDTH ft LENGTH $ DEPTH ft i <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> h <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft P <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ` ft DEPTH R I' <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft. PROPERTY LINE ft <br /> 0 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 /> 1NIMU 24 HO. R V C N C RE UIRED FOR INSP LEASE ALl 9)953-7697 <br /> SIGNED TITLE DATE <br /> Y. <br /> J <br /> I <br /> r <br /> I <br /> i� <br /> F <br /> r I I <br /> ARTMENT USP-ONIAY <br /> Application Accepted By Date " l`1' Area Employee ID# -737 <br /> Final Inspection By Date�p/�/^ z 11 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PiNump Soil Character: <br /> COMMENTS 8�J "7`c�F %c .2 ra r9A � -Z(✓ "S <br /> 6"L 6"dI 'tPE ,,, SC Received C eck#1 Amount Permit/ <br /> Code xS,INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12122/2003 <br />