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CANWDQNSITE <br /> WA ,WATER TREATMENT SYS M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL�._ �RTMENT 304 E WEBERTE -3"°FL-STOCKTON CA 95202 - (209)408-3420 <br /> NON-REFUNDABLE PERMIT ' CALL 209 953-;697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> /� T :' <br /> JOB ADDRESS ✓ •o 'CITYIZIP <br /> CROSS STREETS 1; APN LAO PARCELSIZE <br /> o <br /> PHONE/ -i ! <br /> OWNER NAME ?' <br /> OWNER ADDRESS CITYISTATE/ZIP [ <br /> CONTRACTOR 0 PHONE Y2 <br /> d - <br /> I <br /> CITY/STATE/ZIP ti <br /> CONTRACTOR ADDRESS <br /> i i : <br /> LICENSE ❑C-42 L3 C-36 OTHER NUMBER 1 . EXPIRATION DATE _ <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y r <br /> PERC,TEST # BUILDING PERMIT# I ' LAND USE APPLICATION# <br /> ,�.. . <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> r INSTALLATION WILL SERVE- --;'❑,RESIDENCE _ .❑ COMMERCIAL O OTHER <br /> 4 � NUMBER-OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY. gal #OF COMPARTMENTS r <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> 1 i <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST'.WELL ft FOUNDATION 1 ft PROPERTY LINE t� <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> � i <br /> ❑ . LEACH LINES © LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> I <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 t ft DEPTH <br /> Ig DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINF. ft <br /> I ❑ 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 /> PROPERTY LINE ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PR- <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 DONF IN ACCORDANCE WITH SAN JOAQUIN COUNTY ` <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—qLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE # DATE <br /> � I <br /> k <br /> II <br /> 1 t5v rr <br /> Ci L <br /> P. <br /> 3- <br /> Lr f <br /> 4 <br /> ` .. I1EP.ART"FNT]MSE.O&LY-.az%:O�- <br /> Application Accepted ByDate Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept f 3 FI: PitlSump Soil Character: <br /> COMMENTS <br /> lam' <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# PermitlD# <br /> Code INFO B as Remitted Service Request# <br /> 222 .� .� �f3 ! �Co D 42pp 9 <br /> F ] <br /> F} <br /> ONSITE WASTEWATER PERMIT <br /> -42-02-601 <br /> .1212212003 . <br />