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ONSITE WA'''EWATER TREATMENT SYF"!'� M PERm <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER xvE -31tD FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> CROSS STREET APN f�� lJ(f p PARCEL SIZE f r v <br /> 0 <br /> i OWNER NAME PHONE. <br /> OWNER ADDRESS 7 1i CITY/STATE/ZIPi�cX (aj <br /> CONTRACTOR AL 1- L �i Of. PHONE _3-76 I <br /> CONTRACTOR ADDRESS C CITYISTATEIZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT_# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBEROF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ 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 /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LI LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft f� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION Y ft PROPERTY LINE ft V <br /> ! <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 L <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft rl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH A DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION "* ft PROPERTY LINE ft 1 <br /> 1' <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIND M 24 H R N NOTICE REQUIRED FOR INSPECTIONS-P FAWCALL(209)953-7697 /�� <br /> SIGNED �� TITLE' P. DATE.(� �� <br /> r 1 <br /> IMAC EMI <br /> II C U <br /> 1� ,I R N l= F <br /> 1 <br /> 5 <br /> - - - ---- <br /> DEPARTMENT U E NLY r <br /> Application Accepted By Date Z G _- Area Employee[D# 7l Q7 <br /> Final Inspection By Date ❑ ,SPECIAL PERMIT-Approved by <br /> i Character of Soil 1,,WfiS1irgp'Sali Character: <br /> COMMENTS <br /> AA, 4 A-- �� <br /> PE SC Receivedhe Amount Date Permitl Invoice# Permit]D# <br /> Code INFO By <br /> t� �Cash,r� Remitted Service Request# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12122/2003 <br />