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A- ' NNED G� <br /> ONSITE WA; 7-WATER TREATMENT SYS- ,M PEI <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH-0YEPARTMENT 304 E WFBER�,E -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL,(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> y�, CITYIZIP ti <br /> JOB ADDRESS Z-L '72-3: — <br /> (��.a <br /> CROSS STREET L !,J! �-l.+ f A PNi 7 2_3- — L� PARCEL SIZE I G C <br /> `� �� A <br /> OWNER NAME I_ l 1 K �- r �a PHONE <br /> l <br /> OWNER ADDRESS S La <br /> .I— <br /> 1 'j PO h CITY/STATE/ZIP <br /> CONTRACTOR O PHO 7 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRAT. N E r 1.11r 11 1 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # QUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRlADDITION ❑ ENCINF.E;R DESIGNED/ALT0NIdATIVE <br /> ❑ REPLACEMENT L) DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVINC UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: \J <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPFJMFG CAPACITY gal #OF COMPARTMENTS <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) in <br /> ❑ LEACH LINES ❑ LEACHING CLAMBERS #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 /> D[STANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WMTH ft DEPTH ft <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. SC-') <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 fl ^S <br /> SIGNED TITLE DATE 10 1 Z'0 � <br /> o S <br /> 1 <br /> IDMS <br /> + TUI <br /> LPA Y <br /> E f <br /> OAN <br /> TZ <br /> Q IN O N <br /> EA 7 D PA <br /> IL <br /> DEPARTMENT-U EON Y <br /> Application Accepted B - Date41-1 <br /> .� Area Employee ID# <br /> Final Inspection By fl Date �I—� -9ZGd r ❑ SPECIAL PERMIT Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Sail Character: ►�. <br /> COMMENT Z,88 _2�f �. !`j .5/ 2 -aS,(- 14 D-1z�V-CRY <br /> PE Sc Received Check#/ Amount Date Permit! Invoice# Permit ID# <br /> Cade INFO B Cash Remitted Service Re uest# <br /> ONSITE WASTEWATER PERMIT <br /> 42-02-001 <br /> 12/22/2003 <br />