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ONSITE WAS' WATER TREATMENT SYST 4 PERMIT <br /> SAN JO IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Ave -3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> N -REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS kXPIRES 1 YEAR FROM DAT 'b <br /> JOB ADDRESS CITY/ZIP <br /> CROSSSTREET APN r�)Z D,?v`O,:/ <br /> PARCEL SIZE � <br /> OWNER NAME PHONE ✓P/0 111 <br /> OWNER ADDRESS CITY/STATE/ZIP /,, 2 <br /> CONTRACTOR PHONE 1`6/? //_'// L <br /> 61 <br /> CONTRACTOR ADDRESS77 CITY/STATE/ZIPffl <br /> �� ( h0 Z4 4— <br /> LICENSE 42 <br /> Ll OTHER NUMBER 2f�s EXPIRATION DATE V O <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ' <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION AkF REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL moi{ ❑ OTHER <br /> NUMBER OF LIVING UNITS: z NUMBER OF BEDROOMS: J NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG 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 /> BLEACH LINES AILEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ 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 /> ❑ DISPOSAL PONDS WIDTH ft 'LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ASEEPAGE PITS WIDTH ft LE ft DEPTH � ft <br /> DISTANCE TO NEAREST WELL / / // ft FOUNDATION �fl PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND`THE�WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPEC 'IONS-PLEASE CALL(209)953-7697 <br /> SIGNED �� -� PITLE O DATE <br /> V <br /> jjjj 1q% <br /> ell <br /> LA <br /> G' <br /> o <br /> G <br /> P N M <br /> 5 p <br /> s <br /> DEPARTM NT PSE ONLY <br /> Application Ace e d By �-- Date 23 Area Z Employee ID# '573 <br /> Final Inspection 1)ate3�o���Q y ❑ SPECIALfjPE.R-/MIIT-Approved by <br /> Character of Soil to Depth 3 Ft: Pit/Sump Soil Character: --crt <br /> la <br /> -1- S <br /> CO ENTS �[� ,n,u.�.st� asU - ` olti [I r,ic /cJ ICSH <br /> PE SC Received ec / Amount Permit/ <br /> Code INFO B ash Remitted Date Service Request# n # e t # <br /> AL2- ���. �� p <br /> D � <br /> 42-01-001 <br /> 12/2/02 ONSITE WASTEWATER PERMIT <br />