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OM c n <br /> ONSITE WA... ,EWATER TREATMENT SY&. M PERMIT QIUN <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"' FL-STOCKTON CA 5 1 421 20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS .O S o•� Pi CITY/ZIP n <br /> CROSS STREET M Cj A' J APN m O K Z-0Z PARCEL SIZE \' 0C) C <br /> q 0 <br /> OWNERNAME \ �i�[ PHONE <br /> OWNER ADDRESS Ibb `p <br /> T-C CITY/STATE/ZIP1--a. Z 1S <br /> CONTRACTOR L4 0 PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE O C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION#, 0$--709 /4 <br /> i <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 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> U <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft C <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE it <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft L <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 'TQ <br /> ❑ SUMPS WIDTH R LENGTH R DEPTH ft C <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 R FOUNDATION ft PROPERTY LINE R 'S <br /> r <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFV 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 /> MIN UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 � 1 <br /> SIGNED TITLE Go�s�\. ,e DATE A04 �'• •10 7p <br /> CA I <br /> d <br /> A <br /> N H G U <br /> D p <br /> DEPARTMENT YSE <br /> Application Accepted By �'v- Date ,, //-//Z-D 0 Area Employee ID# <br /> w-zey- ? <br /> Final Inspection By 7 - Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS ��L�ir c Fgrt�J ' J /� � �C� I i� moi') :�J) <br /> PE Sc Received ecldl Amount Date Permit/ Invoice III Per lD# <br /> Code INFO B Cash Remitted Service Re uest# <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 1222/2003 <br />