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I <br /> ONSITE WA.. iEWATER TREATMENT SYS,-EM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3'05 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT /�-- CALL 209 953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS `]5�� L� L rit,t- 1�� , CITY/ZIP <br /> CROSS STREET G�+ lGfpl/ APN - PARC 12 9 <br /> v <br /> n r v <br /> OWNERNAME S�4L/�_ 1� iL/�. PHONE <br /> F OWNER ADDRESS CMISTATE/ZIP <br /> I+� CONTRACTOR O PHONE -7 <br /> q CONTRACTOR ADDRESS O CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NumBElk EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> it PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> i <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 TYPF/MFG CAPACITY gal #OF COMPARTMENTS 4 <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 /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> ft <br /> DISTANCE TO NEAREST FELL ft FOUNDATION ft PROPERTY LINE <br /> 13 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 R <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 /> F ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE. ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> f SIGNED TITLE �,C 1DATE 4A/0 y <br /> /( <br /> /1k A CAI <br /> Q 4N. O <br /> EPARTMENT U E O YLV <br /> Application Accepted Date 3 Area Employee ID# <br /> Final Inspection By Date 7 " ❑ SPECIAL PERMIT-Approved by / <br /> Character of Soil to Depth of 3 Ft: PitlSump Soil Character: <br /> COMMENTS <br /> 5 e o F'a 11 ,'vi '30 +-In j vl I C <br /> PE SC Received Che Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> ¢2zz Sz1 � a 51 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />