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ii•yv <br /> ONSITE WAST�p�y ATER TREATMENT SYSTE.r PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALF DEP.I�A ENT 304 E WEBER AVE�FL-STOCKTON CA 95202 - (209)468-3420 <br /> .NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS -Lr 'Z ` ' jjtTn 2! /Z <br /> CITYIP I�f�64M dy m <br /> a <br /> CROSS STREET Li I `CLi APN HOZ;— OST'— !Fs'Z- PARCELSI'LE y PCS p <br /> _ 1 <br /> OWNER NAME ��lI �� PHONE �Zy -�i 3i <br /> OWNERADORESS IDD0 Cwt" NC.Y" 1%jZ— CITY/STATE/ZIP <br /> 'Nn <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP ` <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 91, PERC TESTS) NUMBER LAND USE APPLICATION# 7AZany 3C7 <br /> TYPE OF WORK: ❑ NEWINSTALLATION ❑ REPAHUADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: n <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS y/ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION R PROPERTY LINE f1 <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 11 FOUNDATION R PROPERTY LINE it <br /> ❑ FILTER BED WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION tt PROPERTY LINE R <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ SUMPS WIDTH R LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH ti <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ SEEPAGE PITS WIDTH R LENGTH R DEPTH 11 <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTI'. _ <br /> e�q��J <br /> MINIMUM HOUR ADVANCE NOTICE:REQUIRED FOR INSPECTIONS-PLEASE CALL(209)951-7647' <br /> SIGNEUDjl'-Ilf 1. 77,�L TITLE DATE 'I <br /> IT <br /> 141 N <br /> cz:17 <br /> r <br /> lk� cc <br /> Y <br /> N <br /> N 1J - 0 SS10N <br /> LOZ <br /> f• <br /> .r <br /> DEPARTMENT YSEPNLI � �— <br /> Application Accepted By /'Date 3 A a Employee ID4_ / <br /> Final Inspection By Date IT-Approved by �I <br /> Character of Soil to Depth of 3 t: Pit/Sump Soil Character: <br /> WNIMENTS n A2� i G 'T S <br /> a�t3id��ASf s l/ (r4fiZ Y2,h,r= / drio <br /> PE SC Received Check#/ Amount Pe ii/ <br /> Code INFO I By j Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 42-01-001 '7 l % - Y. i ('.,( %'I/' <br /> 12/7/02 ONSITE WASTEWATER PERMIT <br />