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ONSITE WAS EWATER TREATMENT SY,.,oEM PERMIT /j <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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z r n CITY/ZIP y <br /> CROSSSTREET � ' G APN ��'- I1 U I PA EL SIZE�1' ' <br /> OWNERNAME 1 \ ✓ RM�1 C:�� PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR �0 PHONE - <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinated 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 /> ❑ SEPTICTANK TYPFJMFG CAPACITY gal #OF COMPARTMENTS l <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS f <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION It PROPERTY LINE ft J <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft / <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LME ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R 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 <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <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. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2D9)953-7697 �^1 <br /> SIGNEDTITLE DATE T J <br /> 5 <br /> R <br /> PR E <br /> DEPARTMENT E O Y V� <br /> Application Accepted Data Area Employee ID# <br /> Final Inspectio ate / —7 ❑ SPECIAL PERMIT-Approved by <br /> Character of it to of 3 Pit/Sump Soil Character: <br /> COMMENTS <br /> <57 <br /> PE SC Received Amount Date Perml4 n oice# _ <br /> Code INPO B Caah Remitted Service R uest# <br /> s16 01 -VS- <br /> 42-02-001 <br /> S 42-02-001 ONSITE WASTEWATER PERMIT <br /> )28212003 <br />