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(o :�'o /�� <br /> ONSITE WA�'EWATER TREATMENT SYL,..,]M PERMIT <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 AYEAR FROM DATE ISSUED <br /> JOB ADDRESS r/'J/7,7�'/"- (�PtS T N) WAX /�0 CITY/ZIP <br /> CROSS STREET ,ryViCl,S�j,N/ izeAb ` !� c A P N - '-O3U --23 PARCELSIZEZC2 C <br /> OWNER NAME /�!K• ANiolzk +t.J J ?-:5 PHONE <br /> J <br /> OWNER ADDRESS �� 3(� SoGl rN M/ LL CITY/STATE/ZIP m4 AI TEL'SIA <br /> CONTRACTOR I�l 6/ PHONE 'q'U <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP S <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> W'A ER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y Q <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION#PA <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 /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE 1t <br /> Ix <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #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 /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 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 /> HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 / f <br /> SIGNED TITLE A1WN� DATE J` �/- a Z <br /> I, <br /> N T <br /> n PA T <br /> 6 <br /> DEPARTMENTNN <br /> Application Ace ted Date Area Employee ID# � <br /> Final InspectionDate ElSPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of Ft: Pit/Sump Soil Character: <br /> COMMENTSC� <br /> n-77— <br /> PE <br /> PE SC Received C Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By as Remitted §ervice Request# <br /> q7Z7—. 571 ��D19,,C- 0© i Sou <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />