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ONSITE WA TEWATER TREATMENT SYr TEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL',*rDEPAR-I'MENT 304 E WEBeyfVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP �SC.n�O� S3clI / LA <br /> f 1 C I o � <br /> CROSS STREET U`C\ APN / f D ! PARCEL SIZE �� / <br /> _ °v <br /> OWNER NAME LJ� n ONE C <br /> _ <br /> tom/ v <br /> OWNER ADDRESS [[ / ,TI <br /> A ff%Lci�j nC�r. <br /> CONTRACTOR 1 - Ci G I �/ PHONE `, (� �7 '�(�C1 <br /> CONTRACTOR ADDRESSCITY/STATE./ZIP <br /> LICENSE ❑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 ❑ OTH R <br /> NUMBER OF LIVING UNITS: J NUMBER OF BEDROOMS: [7C NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY �w gal #OF COMPARTMENTS d. <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE Qc)/ <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) I (� <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 A DEPTH ft <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 <br /> ,iol ft <br /> SUMPS WIDTH ft LENGTHN-D, ft DEPTH ft <br /> DISTANCE TO NEAREST WELL )3S� ft FOUNDATION CADD ft PROPERTY LINE <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 /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> '1�-i; IRED FOR INSPECTIONS'-PLEAS CALL(209)953-7697 <br /> SIGNED TITLE DATE —V <br /> -117 <br /> I VT <br /> f/ o <br /> I LP <br /> 41 <br /> K <br /> X <br /> Q IN C <br /> �n NVR M T <br /> T <br /> FL A <br /> LL <br /> ( iDEPAR I NI L's f ISE( 'SLS' <br /> Application Accepted By Date �LS �� Area Employee 113# q3C <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dep �of 3 Ft: Pit/Sump Soil Character: <br /> COMP NTS y <br /> PE SC Received C eck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By s Remitted Service Request# <br /> Z -3 <br /> 42-02-001 ONSITEATER PERMIT <br /> 12/22/2003 <br />