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Mfr-' �v <br /> CANNED <br /> ONSITE WA�)EWATER TREATMENT SY�°7M PERNff <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBEfi AYE -3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> CITVIZIP <br /> JOB ADDRESS <br /> CROSS STREET Iw APN V PARCEL SIZE Ta A <br /> P0 <br /> C( <br /> OWNER NAME PHONE 'n <br /> OWNER ADDRESS C CITY/STATEIZIP_O!� � 17 17 i5�0 <br /> CONTRACTOR <br /> r ' PHONE ~3-76I <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> i LICENSE El C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> Ll PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION LI ENGINEER DESIGNED/ALTERNATIVE <br /> El REPLACEMENT <br /> El 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 /> y ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> D LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft q <br /> DISTANCE TO NEAREST WELL ft FOUNDATIONC _R PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE _ _ ft L <br /> 0 MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> i DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ti <br /> pr ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> 4 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft T <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH <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,ST E LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINI M24 H RN NOTICE REQUIRED FOR INSPECTIONS—P E ALL(209)953-7697 r <br /> r <br /> SIGNED TITLE T) C.�( _ DATE t / <br /> A <br /> MAI <br /> 1(hAQUIN COU141 <br /> N lR( N E <br /> t <br /> Al <br /> i <br /> s <br /> t <br /> r � <br /> % DEPARTMENT U E NLY - <br /> Application Accepted By Date Z 7 Area Employee ID# 77 4 � <br /> Final Inspection By Date ,'�>i /p ❑ .SPECIAL PERMIT-Approved by <br /> Character of Soil t e iY ' ��'—'� - `�; y"t�ul��Soil Character: <br /> COMMENTS jP <br /> PE SC Received hec Amount Permit) <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 42-42-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />