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SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> WAS-OVATER TREATMENT SYS& PERMIT <br /> 304 E WEBER AVE -3RD FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT , CALL 4209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS r CITY/ZIP_� T� c_G <br /> CROSS STREET I—sSH "pTGNERq fAnpV{L)v `Z APN <br /> C <br /> //^^ PARCEL SIZE )i JO S o <br /> OWNER NAME QST A V I l lyf1 z <br /> PHONE to <br /> y <br /> OWNER ADDRESS <br /> CITY/STATE/ZIP <br /> CONTRACTOR <br /> PHONE <br /> CONTRACTOR ADDRES CITY/STATE/ZIP <br /> LICENSE Ell C-42 Ll C-36 OTHER CE;-- NUMBER <br /> EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> Y <br /> J PERC TEST # 3 BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION <br /> ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ,eI COMMERCIAL ❑ OTHER n' <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br /> NUMBER OF EMPLOYEES: I n <br /> SEPTIC TANK TYPE/MFG_ Un CAPACITY <br /> gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY <br /> gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE <br /> ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES <br /> ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ FILTER BED WIDTHft , <br /> ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH ft <br /> ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SUMPS WIDTH ft <br /> ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTHft <br /> ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ftFOUNDATION ft PROPERTY LINE <br /> LI SEEPAGE PITS NUMBER ft <br /> WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ft <br /> I 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 /> SIGNED 10, MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> �i� j <br /> TITLE Sa-Aq1= 6� n DATEJ1 -1 $ <br /> Application Accepted By <br /> Date / <br /> L �� Area Employee ID# Z <br /> Final Inspection By C� Date (/ / ❑ SPECIAL PERMIT-Approved by 1 <br /> Character of Soil to Depth of 3 Ft: C-i— PIt/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received heck# Amount Permit/ <br /> Code INFO B ashDate <br /> 2 Remitted Service Re uest# Invoice# Permit ID# <br /> 42-02-001 <br /> 12/22/2003 ONSITE WASTEWATER PERMIT <br />