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ONSITE WA` '�EWATER TREATMENT SYS' ?M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI�JEv PARTMENT 304 E WEBEkVl',OE -39°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> (J u - a CITY/ZIP ZAT/f UA `Is3sv <br /> JOB ADDRESS '1 <br /> t'� p /� Q� <br /> CROSS STREET Z' S APN /1/ V 7O V lD PARCEL SIZE <br /> b <br /> OWNERNAME WAL/GR 4a Ecia PHONE <br /> .0-z <br /> YC � <br /> OWNER ADDRESS •• t /e7 -"�- CITY/STATE/ZIP A 7 he-0 j If <br /> A fs Y6 <br /> CONTRACTOR 1..� /v C.T/H�S Irk U%Nr( PHONE I <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 , OTHER NUMBER EKPIRATION DATE/ <br /> WATER TABLE DEPTH: Iy / it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# Nfl+ <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS tri <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS N <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES it <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME it <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LME ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LME ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> 1 HEREBY CE IFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> NANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIN UR <br /> A,D�VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED Z W' TITLE 0JAIN15tZ DATE <br /> 00, <br /> rA <br /> I <br /> ri,VIF or,ME qT <br /> I1 1 H EN THDEDAF <br /> T <br /> q <br /> 1z&w R7.X0T USE CiNLV <br /> Application Accepted By Date f �" 7d Y Area N'/n Employee ID# <br /> Final Inspection By Date '� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received eck# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Re uest# <br /> o'Z l)S <br /> 12 <br /> Z2 <br /> 42-02-00I ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />