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f L ' 30ONSITE WAST ATER TREATMENT SYSTF `PERMIT .0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AvE-+4PFL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE/P}EERMIIT, CALL( 9)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED r <br /> JOB ADDRESS -�/ t? ✓ O CITY/ZIP .] Z L/I <br /> y <br /> CROSS STREET APN O 2 i�,�Q i <br /> �P RCEL SIZE T? IC <br /> OWNER NAME ev vl� PHONE <br /> OWNER ADDRESS CITYISTATEIZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATF./ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EX D <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> PERC TEST # BUILDING PERMIT# CAND USE APPLICATION# <br /> TYPE OF WORK: [3NEW INSTALLATION L3REPAIRIADDITION C3ENGINEER DESIGNED IALT?TIVETIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> �1 <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER I �] <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: VO <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 /> Cl LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ti <br /> DISTANCE TO NEAREST WELL R FOUNDATION fi PROPERTY LINE II a <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH fi <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 LINE fi <br /> ❑ SUMPS WIDTH ft LENGTH J1 DEPTH ft w <br /> DISTANCE TO NEAREST WELL RFOUNDATION ft PROPERTY LINE ft , <br /> ❑ DISPOSAL PONDS WIDTH ft L GTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH fi <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R 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 /> MINIMUM 24 HOUR ADVAN E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �.- TITLEQ'owS DATE <br /> i <br /> cl <br /> oC S L I DdAl <br /> � a <br /> ELLffg�-i- i-H <br /> I I I <br /> U <br /> D ARTMENT USE NLY <br /> Application Accepted Date v a � Arca - Employee IDS y/ <br /> Final Inspection By a /l H d ❑ SPECIAL PERMIT-Approved by / 9 <br /> Character of Soil to p plh o 3 FI: it/Sump Soil Character: <br /> COMMENTS / �c� ���i> ctt4' �� / % j <br /> PE SC Received Check# Amoual Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service R uest# <br /> Z 5� <br /> ? � to <br /> A2-02-0+11ONSI�ASTEWATER 111111f �(l <br /> 12,22,2003 <br />