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ONSITE WA, EWATER TREATMENT SYS �M PERMIT ,�NED <br /> �... <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3""FL-STOCKTON CA 952 Y- (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V <br /> 7 N l 1OLJ� CITY/ZIP <br /> ,fT ������ / 7 <br /> CROSS STREET / / APN ��/ `yl�--03 PARCEL SIZE ! , 7 / 2 0 <br /> OWNER NAME !� S L.t� PHONE�v�_�OI- $�� I <br /> OWNER ADDRESS CITY/STATE/ZIP �5K— r/1 ��/�/0 <br /> CONTRACTOR PHONE �Q/ / 7� /�Q� <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE Cl C-42 ❑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 /> ❑ 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 /> GC <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 D <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft r <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 /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> �RDTNAT� E LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 1 <br /> N I M 24 HOUR ADVAN 'NOTICE REQUIRED FOR INSPECTIONS-PLEASE CA ,L(209)953-7697 ` <br /> SIGNED TITLEi1't'/s�Tfrb1./yC�/��'� DATE <br /> a <br /> p - �. <br /> O N <br /> A DEPARTMENT! <br /> Application Accepte*Deof <br /> '�� Date 0 0 Area Employee ID# <br /> Final Inspection By J Date El SPECIAL PERMIT-Approved by <br /> Character of Soil to 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS D�5Lt �t r nu.--) 0 F- S-172u 6 Tu S Lf-tt.c�uH ��C ►�uM ten) Shu 6"C- <br /> PE Sc Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> Z_ Cr OSS <br /> ONSITE WASTEWATER PERMIT <br /> 42-02-001 <br /> 12/22/2003 <br />