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ONSITE WASI..,ONATER TREATMENT SYSTI,,W PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMF.NTAi.HEALTH DEPARTMENT 304 E WEBER AVE -3"°Ft.-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 2- v , n ` CITY/ZIP / C A- <br /> M~t� <br /> CROSS STREET V� —� APN� 0 U�j � �� -7i� PARceI.Slre a�� o <br /> OWNER NAME: PIIONE: ZJ rj <br /> u ti, Z/ 77 —t--1 �� 1J-� � c'rrY/S'E,vrr://Ir -�,� �V �S_:<-� <br /> OWNER ADUREss -- --__ _. _ —,-._�� -- �q\1 <br /> CONI RACI OR IIHONk: ' <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE. ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: 11 GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> -0 PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION#_Ih -O!-t <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 tt 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 <br /> DISTANCE To NEAREST WELL 11 FOUNDAI ION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fI <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> r <br /> ❑ SUMPS WIDTH 11 LENGTH ft DEPTH ft �.. <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH 11 DEPTH ft <br /> DISTANCE 7'O NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <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. n <br /> MINIMUM 24 HOU"DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(20x9)953-7697 �1 <br /> SIGNED TITLEF v.��•• �}��S��V ACDATE �• �• N��� <br /> J <br /> JA 'J fIIJ U TY <br /> H I �' NT <br /> Gti ' e, r <br /> PGoT PL on- <br /> �- DEPARTMENT t SE ONLY �� <br /> Application Accepted �311FI: <br /> ��— Date L` F.. C�;J Area Employee 1D# S-S't C-- <br /> Final <br /> �)� <br /> Final Inspection B � Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to h Pit/Sump Soil Character: <br /> COMMENTS . <br /> PE SC ReceivedCheck# Amount Date Permit! Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> _ / <br /> 42-02-001 ONSITE WASTEWATER PERMIT 1\_ <br /> 12 22 2v03 <br />