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�' 'I <br /> ' �'` ONSI WAS" ',WATER TREATMEN `STYSTPERMIT <br /> SAN JOAQUIN COUNTY ENV IRONlyIENTALHFALTH RTMENT <br /> .30¢ 3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE <br /> PERMIT ,, i j "CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED. <br /> JOB ADDRESS r Cr 4j VV' W ' CITYIZIP 2- <br /> CROSS STREET APN_&55- IIzD~�a Z3 PARCEL SIZE <br /> {444 <br /> ,PHON te to <br /> M <br /> OWNER NAME Yn <br /> � '� <br /> r <br /> OWNERADDRESS _ `T 1 � JAI , Z _ CITYISTATEIZIP <br /> 1p f -5 4 <br /> CONTRACTOR < <br /> fi SdC PHONE <br /> CONTRACTOR ADDRESS OZ CITYISTATEIZIP C -- <br /> LICENSE a ❑C-42 L3 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> W PERC TEST(S) NUMBER 44 LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED(ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: N <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG-TX PLANT DISTANCETONEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> E ❑ LIFT,STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 1 <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 /> i ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ..... ft FOUNDATION ft PRpPERTYLINE <br /> I I - <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 WIDTH ft LENGTH 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 DOAE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 5 , <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE 1 DATE�f L1 Y <br />} t� <br /> t <br /> 57 <br /> 9 y s r <br /> N <br /> t <br /> r� <br />[ ✓. 7 A J AQ IN <br /> 51 1,2P IT <br />` A—Heation Accepted r Date 111 b Area f Employee[D# <br /> P nal lr pecInn B` Date ❑ SPECIAL PERMIT-Approved by- <br /> Character,of Soil epth of 11 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE Sc Received C ec Amount D to Permit/ Invoice# Permit I <br /> Code INFO Cash Remitted Service Request#. <br /> 42-OI-001 �� �� ��d � �_lltcf ONSITE WASTEWATER PERMIT <br /> 12/2/02 <br />. '-5_"I��? ter: ---��.�,....:� �- _ - -.°•'- - <br />