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A-yl <br /> ONSITE WA,,,,'EWATER TREATMENT SY( VM PERMIT �� ,�(VED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"'FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CAI,1, 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ' N r (OLJ�` "� / CITY/ZIP ����1 <br /> CROSS STREET - t / / APN �/ /' �lf�-"C3 PARCEL SIZE 1, 77 <br /> (' , 7 7 f 2-, <br /> p <br /> OWNER NAME �/ 4S L�--+� [�� PHONE���_(L7'C./i/� (J�r a` m <br /> OWNER ADDRESS /(.�� C Y/S Z) <br /> CONTRACTOR / Mhz / <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE L3 C-42 L3 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 ❑ 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 <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG 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 ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 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 <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> Tw,AvV, E LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. L <br /> r <br /> 1 1 1 M 24 HOUR ADVAN NOTICE REQUIRED FOR INSPECTIONS-PLEASE CA.L(209)953-7697 <br /> SIGNED / TITLE�A�rk S rbc./v l�/��f DATE <br /> L-7 <br /> L7N - <br /> N O N <br /> DEPARTMENT U E ONLY r <br /> Application Accepte;�P3 <br /> By t '—�� Date L) CI�' Area Employee ID# �� � U <br /> Final Inspection BV J Date t' ❑ SPECIAL PERMIT-Approved by ! <br /> Character of Soil to DFt: Pit/Sump Soil Character: <br /> COMMENTS ei1-( ,L r n J pFS't�?u c lir �' ES C'rrcc�ec ly t�"EC v iM /�n� i�cct��1Cr <br /> Ae <br /> 51ZtE. <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> 2 r O`�05 o .op \ NO Db <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />