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l 0 - ` ONSITE WA,I, :EWATER TREATMENT SY4..,4EM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3R"FL-STOCKTON CA 95202 - (209)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> .. - _ W <br /> JOB ADDRESS AZ CITY/ZIP A� y <br /> CROSSSTREET 'ji /)( t I APN / 5D k007'L PARCEL SIZE Q o <br /> /� �/� F �63r6'-moo 3!I A <br /> OWNER NAME E/ '✓P'r><�M� uI�ALS PHONE y <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR I G dc U-wC PHONE <br /> CONTRACTOR ADDRESS IFA CITY/STATE/ZIP kj4n,nA,1,A �i <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE (✓ <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION LJ,1 REPAUVADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: U RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ CREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LME ft IN <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) Q <br /> LEACH LINES Lll'LEACHING CHAMBERS #OF LINES � LENGTH OF LINES �dt It <br /> DISTANCE TO NEAREST WELL 151)4- ft FOUNDATION I J R PROPERTY LINE LS R <br /> ❑ FILTER BED WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LME R 4, <br /> IK SUMPS WIDTH R LENGTH loll ft DEPTH /pl <br /> DISTANCE TO NEAREST WELL 1551 R FOUNDATION to I ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R 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. <br /> MINIMUM 24 UROUR ADVVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED "^'— ,IAC/ TITLE COAILrC�rbr DATE <br /> �r <br /> r <br /> a <br /> C.P � <br /> G <br /> P <br /> O <br /> DEPARTMENT U. ONL L` <br /> Application Accepted By Date Area Employee ID# 76 �y�n <br /> Final Inspection By Date 6 ❑ SPECIAL PERMIT-Approved by 7 <br /> Character of Soil to Dellih of 3 Ft: 7 j7.hSump Soil Character: <br /> COMMENTS <br /> a !O <br /> 'IF 611 <br /> PE SC Received eck#/ Amount Date Permit/ Invoice# Permit lD# <br /> Code Ingo BY- Cash Remitted Service Request# <br /> i s <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />