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Q A,N1' ED <br /> ONSITE WA01 EWATER TREATMENT SYc ':M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBE12'7R'E -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXP ES j YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> m <br /> CROSS STREET \ APN � O ,( f <br /> PARCEL SIZE �. <br /> O <br /> F <br /> OWNER NAME - IL/t PHONE <br /> OWNER ADDRESS1 2 p.T'W\f'\�1.. f'C�/ "_ CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> I t go as WWI a <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: tt GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALT ATI\'E <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 /> Al <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) Jam' <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft S <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 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 (O <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft 1 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 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 ADVANCE NOTICE EQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 pp <br /> SIGNED TITLE�i� h- � DATE <br /> 1X1.911' DI <br /> F <br /> -NET -0.5 5.-NET ` <br /> loo/ a <br /> 1 Y <br /> ps <br /> �W An`n/ �pC, O <br /> NORU-W p <br /> ?l5.f1' <br /> -------------=s-- - ------ N O O M E <br /> I 1A I 1k) i 1/ 1) 1 L I I <br /> /DEPARTMENT USE Ll' <br /> lvqApplication Accepted By ' Area / Employee ID# <br /> Final Inspection B,v Date ❑ SPECIAL PERMIT-Approved by ` <br /> Character of Soil to Depth of 3 Ft: Pit/Sumn Soil Character: <br /> COMMENTS , R( dGL� <br /> An <br /> cry` -, 2. <br /> PE SC Received hec Amount at Pert/ Invoice# Permit ID# <br /> Code 77 INFO By ash Remitted Service Request# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />