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ONSITE WAS' ;WATER TREATMENT SYSM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH'L,.PARTMENT 304 E WEBER­_ -3" FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE P MIT CALL 249 953-7697 FO INSPECTIONS E P RES 1 YEAR FROM,DATE-ISSUED <br /> S <br /> JOB ADDRESS f C1T1,IZIP <br /> .Ilf W - 10 I /fie a <br /> CROSS STREET APN PARCEL SIZE <br /> OWNER NAME L�/��OWNER ADDRESS CITY/STA (07 <br /> CONTRACTOR dV /-� w J� PHONE <br /> CONTRACTOR ADDRESS L) CITVISTATE/ZIP ` <br /> LICENSE C42 ❑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 U DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIV INC UNITS: NUMBER OF BEDROOMS: o NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG Com' � f ¢ `--� CAPACITY gal #0FCOMPARTMENTS ba <br /> 1 <br /> I'❑ CREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST; WELL ft FOUNDATION -ft PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> M 1411t <br /> ❑ _LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINELl <br /> ft <br /> FILTER BED WIDTH 30 ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL_ �ft FOUNDATION 10 _ft PROPERTY LINE ft. <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME It <br /> ❑ SUMPS WIDTH ft LENGTH_ ft DEPTH ft <br /> DISTANCETONEAREST 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 /> E ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH - R <br /> c DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 /> C M MUM 24 HOUR A VA.NCE NOTIC 'REQUIRED FOR INSPECTI NS—PLEASE.CALL(209)953-7697 ,, L <br /> TITLE DATE <br /> SIGNED <br /> EETTED <br /> 4 <br /> 05 <br /> NTY <br /> L <br /> Ft <br /> T .D Q .T Etsf <br /> I <br /> r <br /> - DEPARTMENT USE NL <br /> Application Accepted B Date o Area Employee 1D# <br /> ! Final Inspection By Date Z / O ❑ SPECIAL PERMIT-Approved by, / <br /> Character of Soil to Dept of 3 Ft: PitlSump Soil Character: <br /> COMMENTS / <br /> ! lac Azez&-+%5� ' .)... ;fie✓( <br /> PE SC Received. ' Check#! Amount Permit/Code INFO B S Remitted Date Service Request# Invoice# Permit 1D# <br /> g� `� D <br /> \ 42.02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 ' <br />