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ONSITE WA)bWEWATER TREATMENT SW, M PERMIT <br /> a � <br /> ° <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBS VE -340 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT qua/ CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM PATE ISSUED <br /> JOB ADDRESS T« 6 CITY/ZIP f.r rl.l LA <br /> H <br /> 1 n <br /> CROSS STREET " / tSC ATN_ 00-7-,;t 3 PARCEL SIZE 5, 0 > <br /> OWNER NAME <br /> OWNER ADDRESS - "' ITY/STATE/ZIP �rX& CA (75& <br /> CONTRACTOR ce^ ✓ PHONE 34t'?- <br /> CONTRACTORADDRESS CITY/STATE/ZIP <br /> LICENSE C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft 4 GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION AC REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> p( NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> p1 SEPTICTANK TYPE/MFG 46BWerf *- CAPACITY 6p--- gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> t <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL 120 ft FOUNDATION Za R PROPERTY LME / ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LMes LENGTH OF LINES S✓O ft <br /> DISTANCE TO NEAREST WELL Q + ft FOUNDATION (¢0 1 ft PROPERTY LINE Ro f R <br /> ❑ FILTER BED WIDTH ft LENGTH It 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 LME R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE it <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> y DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> �D SEEPAGE PITS NUMBER I WIDTH 3 r ft DEPTHCa7sMft <br /> 90 v <br /> DISTANCE TO NEAREST WELL {�"f R FOUNDATION �BV R PROPERTY LE OV R <br /> 1 HEREBY CERTIFY THAT 1 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 /> IMUM 24 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209_)953-7697 <br /> SIGNED TITLE DATE <br /> I <br /> 1 I <br /> O N <br /> o . r: yll 01 MNT <br /> - irl 4EW <br /> 1117-1 <br /> 4 i <br /> ry <br /> DEPARTMENT U.E NLV i <br /> Application Am Date�r� Area al 0 Employee ID#✓ J / <br /> Final Inspectf n By Date �a�� L ❑ SPECIAL PERMIT-Approved by <br /> Character of Soff to D �Ft: Pit/SumgSo ratter: <br /> COMMENTS .�FF�� <br /> PE SC Received C Amount Date Permit/ Invoice# Permit lD <br /> Code INFO B Cash Remitted Service Request# <br /> 42-02-001 /y <br /> 12/222003 f-"�ti•.f / sT F <br />