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ONSITE WAS,..,,:WATER TREATMENT SYS�,.M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3N°Fl.-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS U✓ CITY/ZIP v <br /> CROSS STREET ._ /YJ,. t—o ,4g�P—7-d/y� APN Z.S - 2-(030 ARCEL SIZE 3•f' a <br /> OWNER NAME PHONE <br /> OWNERADDR£SS �l �y�L CITYISTATE/ZIP <br /> CONTRACTOR �� ` PHONE �— <br /> CONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE -42 LI C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TAB E DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION CI ENGINEER DESIGNED/ALTERNATIVE <br /> CI REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE J& COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: n r I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> CI SEPTIC TANK TYPE/MFG ej L CAPACITY O - gal #OF COMPARTMENTS <br /> TYPE/MFG aJ PACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDA ION ft PROPERTY LINE ft <br /> LIFT STATION SIZE TYPE OF PUMP � ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> W <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DtSTANC T AREST WELL FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH o-2 ft LENGTH ft DEPTH CL <br /> DISTAN O NEAREST WELL ft FO DATION ft PROPERTY LINE ft <br /> L1MOUNDED WIDTH ft LENGTH ft DEPTH ft r <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft rn <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft v <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CER'T'IFY 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 /> )lMNIM 24 HOU DVANCE NOTICE REQUIRED FOR INS ALL(209)953-7697 L <br /> SIGNED 'J TITLE DATE U <br /> 01 <br /> <6 <br /> is <br /> ,a9` ' � • `',,Q _, �g Pe <br /> EP ENT <br /> s r <br /> Oel <br /> DEPARTMENT E�NLV <br /> Application Accepted By bate 3 4, Area Employee ID# FFG+ S �� <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Spit to Depth of 3 Ft: It/Sump Soil Character: <br /> COMMENTS JD��•�Crr ,�E (Yo"4��..1 C,- STLtd� ,4� �r�y Loo �ryF Go.ccy�• �a , <br /> I-f 6L-0 L_O'T O F SCO 0-,/) <br /> N <br /> " -PE SC Received Check#/ Amount Date Permit/ Invoice# Permit IDA <br /> Code INFO B as Remitted Service Request# <br /> 42—-CS 2.S1 10rS ,fsv-oo Y 3 0 L <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />