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r <br /> ONSITE WAk WATER TREATMENT SYS M <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES ] YEAR FROM DATE ISSUED <br /> JOB ADDRESS �;, V l CITY/ZIP zi <br /> zi <br /> CROSS STREET �Y�j [E.C- APN t�~ Z24P- 0 PARCEL SIZE ire: C <br /> v <br /> j z <br /> OWNER NAME. ? L. try 4'.: d+'► PI N <br /> OWNER ADDRESS / (lY e,,I -v /.�4 �Qai CITYISTATEIZIP <br /> CONTRACTOR (; -f� '"S V�1 '��",lc_ PHONE -3 7e <br /> CONTRACTOR ADDRESS !4 wfr CITYISTATEIZIP Q r <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER ExPIRATION DATE <br /> WATE ABLE 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 ❑ 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 gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ 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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 ft DEPTH ft �J <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft N\ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION - ft PROPERTY LINE ft <br /> I 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. rn <br /> MINI UM 24 O ANCE NOTICE REQUIRED FOR INSPECTIONS--PLEASE CALL(209)953-7697 <br /> SIGN TITLE ( � DATE v \ <br /> f <br /> iT <br /> cc <br /> r <br /> I- <br /> I <br /> ur <br /> N FAL <br /> 1j RC NM <br /> Fff <br /> tj <br /> DEPARTMENT ONLY <br /> Application Ac pled By Date '_//c�Q s� Area Employee ID <br /> Final Inspection By - —:y Date / ❑ SPECIAL PERMIT-Approved <br /> Character of Soil to Dept f Ft: Pit Sump Soil Character-, <br /> I COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Re uesI# <br /> 42-(1201 <br /> 12!22/22003 ONSITE WASTEWATER PERMIT <br /> = <br />