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ONSITE WA^EWATER TREATMENT SY '�M PERMIT +� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL7`ITDEPARTMENT 304 E WEBER AVE -3u'FL-STOCKTON CA 95202 - (209)468-3420 <br /> 11 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS �' -'T CITY/ZIP T S <br /> . <br /> CROSS STREET APN l 7 P RCEL SIZE +L� D <br /> O <br /> OWNER NAME I ♦ �! ��/�. PHONE Z l y <br /> OWNER ADDRESS Y ! q 4 y <br /> CITYISTATEIZIP n 1 { <br /> CONTRACTORO PHO <br /> CONTRACTOR ADDRESS c7 Z n CITYISTATEIZIP P <br /> LICENSE ❑C-42 ❑C-36 OTHER NU BER EXPIRATION DATE <br /> kWATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X y <br /> PERC TEST # 13UILDING 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 /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG _ CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC 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 U <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> k ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft C- <br /> 0 <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 1 <br /> © DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft (t, <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> k ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 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(209)953-7697 <br /> SIGNED TITLE�J DATE <br /> I <br /> Pr P7 <br /> i <br /> 7 <br /> J <br /> >� rV,yo, M U <br /> - r <br /> zz <br /> j DEPARTMENT U E ONL <br /> Application Accepted By / �- Date 2 Area Employee ID# <br /> Final Inspection By Date - ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to pth of 3 Ft: Pitt ump Sail Character: <br /> COEN S <br /> PE SC Received 1 Amount Permit/ <br /> Code INFO B Cash n Remitted Date Service Re uest,# Invoice# Permit ID# <br /> �./ <br /> 07 4 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />