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ep bsDoa3c) <br /> ONSITE WAS' ' WATER TREATMENT SYST M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH IWARTMENT 304 E WEBER)%Pf -3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(2009)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS Ito S G ! 1 I '-i R^ CITY/ZIP STa�+F f011 e-, !± <br /> n <br /> CROSS STREET 141 1 7�/ APN 1'7 3"� PARCEL SIZE <br /> OWNER NAME PHONE <br /> N <br /> OWNER ADDRESS <br /> f CITY/STATE/ZIP <br /> CONTRACTOR inn <br /> �y PHONE <br /> �/ <br /> CONTRACTOR ADDRESS_Q ���( ](� CITY/STATE/ZIP-( 1 }gtj4z- .4- <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE ✓f� <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBERLAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: 503ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBEROF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> W'�S'EPTICTANK TYPFJMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL '^b/ ft FOUNDATION Ip / R PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 'LEACH LINES LEACHING CHAMBERS #OF LMES LENGTH OF LINES R <br /> DISTANCE TO NEAREST WELL CSO 1 R FOUNDATION� R PROPERTY LME ft <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> O Warr" ,y <br /> SEEPAGE PITS Wr" G� f 1 R l.r �... DEPTH --1 ft <br /> DISTANCE TO NEAREST WELL (ate( + R FOUNDATION I C\t R PROPERTY LINE �Z S R <br /> I HEREBY CERTIFY THAT I 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 /> MINIMU,hjJ(124 HH�.l-URR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED -T.LI�� TITLE r ne%j Ib CJYn DATE <br /> 9 <br /> 1 U7 <br /> IMf11 <br /> ko T L <br /> IT <br /> el _ <br /> //P__ LLI DEPARTMENT LSE ONLY q <br /> Application Accepted ey ' [/J I `-� Date D#y�`///Area Employee I // 9 <br /> Final Inspection By Date �' ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth f 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS / <br /> PE SC Received hec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO I By ash Remitted Service Request# <br /> 2 P 3 63 6-003bOS <br /> 42-01-001 <br /> 12/2/02 ONSITE WASTEWATER PERMIT <br />