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<53 <br /> ONSITE WAST TER TREATMENT SYSTEM __ZRMIT vu <br /> ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE FL STOCKTON CA 95202 - (209)468-3420 <br /> k NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS O 3t4 . 4414it CITY/ZIP Zr0 H <br /> ti <br /> r m <br /> Cxoss STREET v APN D J aJ --� 'O C, PARCEL SIZE a <br /> OWNER NAME e 'Qr `-/UVB c7 1 '(�V C 1/� PHONE rmi� <br /> OWNER ADDRESS it CITY/STATEIZIP —Ll Ci►-Y <br /> CONTRACTOR PHONE: <br /> CONTRACTOR ADDRESS 0.Z L' CITY/ TATE/ZIP <br /> 4 <br /> f OA- <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates,, X Y <br /> ❑ PERC TEST # -Z-- BUILDING PERMIT#iuw LAND USE APPLICATION# M'e <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 /> w <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE <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 11 LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED W113TH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 5 <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> © DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 SEEPAGE PITS NUMBER WIDTH ft DEPTH f1 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 3 <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 AD CE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> SIGNEDTIT � N .s��1.�'f_ DATE Z U <br /> 4 F <br /> 0.76 AG Antr •rr, Rt <br /> >DALE ROAD <br /> • r 1 1 <br /> Am P1 P 11 <br /> PLAT <br /> Al <br /> N <br /> t •. 24 �- 19 T T <br /> i - <br /> AD <br /> +4 11 11 11 11 <br /> DEPARTMENTU' ON <br /> . <br /> Application Accepted By Date Area Employee ID# LI <br /> Final Inspection By . Date ��3—nJ� 11SPECIAL PERMIT-Approved by <br /> Character of Soil tp-Depth of 3 176 Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check# Amount Permit! <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit iB# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> ff 12/22/2003 <br /> L_ <br />