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r I ' <br /> ONSITE WASTEWATER TREATM T SYSTEM PERMIT gal <br /> SAN JOAQUIN N&OV ENVIRONMENTAL HEALTH DEPARTMENT E WEBER AVE-3—FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSI ECTIONS J EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CoITi ZI-P <br /> '_ V ` ez) �L <br /> PARCELSIZE <br /> C�1 <br /> 4 <br /> Oi/ :2CROSS STREET <br /> OWNER NAME PHONE aG &0"o <br /> OWNERADDRESS 0kAk-, e01LWV <br /> A� CITY/STATE/ZIP LDD�� 4 7 Sz5D <br /> CONTRACTOR pC-J��� PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> a. <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE y, <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 ZtjG' gal #OF COMPARTMENTS l/ <br /> ❑ CREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> Y� ❑ 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 /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES 12t� ft <br /> a� DISTANCE TO NEAREST WELL ��' ✓ R FOUNDATION J R PROPERTY LINE / ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE fl <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTYLINER <br /> SEEPAGE PITS(4)V-DTH ft LENGTH ft DEPTH G.S Ste_ ft <br /> . DISTANCE TO NEAREST WELL LSG ft FOUNDATION R PROPERTY LINE CN R <br /> ` I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> ATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> INII RA DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED C / TITLE DATE IZ131103 <br /> VAN <br /> EV i!k <br /> -TI <br /> i <br /> laa. <br /> r✓ <br /> VIlotIMENT <br /> DEPARTMENT USE NLY <br /> Application Accepte*p�th�of <br /> -L�-c-� Date 12- 3t 03 Area "Z"f�•— Employee ID# S3 q� <br /> Final Inspection By Date ����_ ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Pit/Sump Soil Character: <br /> COMMENTStet° <br /> ` PE SC Received eck# Amount Permit <br /> Date Invoi # rmlt 1 <br /> _ Code INFO B ash Remitted Service Request# _ <br /> qZ.l) rl� lUo� 3z0-tarp 03 003h530 <br /> :r <br /> baa 42-01-001 <br /> 12/2/02 ONSITE WASTEWATER RMIT <br />