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�- ONSITE WA�EWATER TREATMENT SY; 'M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -Yo FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> CITY/ZIP --��ZO <br /> JOB ADDRESS .-1 <br /> ° <br /> CROSS STREET APN b 12 ARCEL SIZE F <br /> L PHOgui U <br /> OWNER NAME —c Cy IR.t/ iDw w <br /> OWNER ADDRESS CITY/STATEIZIP <br /> CONTRACTOR �.� + PHONE <br /> I� <br /> CONTRACTOR ADDRESS O e� CITYlSTATE/ZIP ? <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE / O <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED IALTERNATIVE <br /> 9 REPLACEMENT . 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ®/RESIDENCE L3 COMMERCIAL ❑ OTHER <br /> t <br /> NUMBEROF LIVING KNITS: I NUMBER OF BEDROOMS: X NUMBER OF EMPLOYEES: <br /> ® SEPTIC TANK TYPE/MFG CAPACITY 2pe U gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION S" ' 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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> IS FILTER BED WIDTH_ IO ft LENGTH Z— ft DEPTH / ft <br /> DISTANCE TO NEAREST WELL 1CP0 ft FOUNDATION D 1 ft PROPERTY LINE d ft <br /> I, ❑ 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 /> r ❑ 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 /> 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 /> INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE � - DATE ~D <br /> I Vo <br /> 4 <br /> i <br /> N <br /> D - <br /> i <br /> 4 <br /> A J AQUllf1C U <br /> .'1144 111 1 <br /> 1 <br /> ki <br /> EPARTMENT U.E ON <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date 3 D [3SPECIAL PERM IT-Approved by <br /> Character of Soil to Depth of 3 F : Pit! ump Soil Character: <br /> COMMENTS: <br /> PE Sc Received ec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Re uesI# <br /> 2 M. <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 1212212003 <br />