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icg2� <br /> ONSITE WA'' �'"EWATER TREATMENT SY4"'7EM PERMIT �--- <br /> R"AQU1N COUNTY ENVIRONMENTAL HEAL'111Pi)EPARTMENT 304 E WEB6%wft -3Y0 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMITS 1/ CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> U 1 zir�l� �� CITY/ZIP <br /> i <br /> CROSSSTREET /2 APN [-( -��Z- •3c.S- PARCELSIZE 4L ' C <br /> 0 <br /> OWNER NAME �/1/L_i �'n �l�✓/y��L/✓) PHONE 71 / �'�YJ� mryn <br /> OWNER ADDRESS CITY/STATEIZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATEIZIP / <br /> LICENSE -42 EI C-36 OTHER NUMBER EXPIRATIONDATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# 6' LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE (S-C9MMERCIAL ❑ OTHER <br /> NUMBEROF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: /0 <br /> SEPTICTANK TYPE/MFG /'•' /.`- CAPACITY gal #OFCOMPARTMENTS Z/ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LME 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 R FOUNDATION JQ ft PROPERTY LINE - it <br /> ❑ FILTER BED WIDTH it LENGTH It DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R / <br /> ❑ MOUNDED WIDTH R LENGTH It DEPTH R _V`1 <br /> DISTANCE TO NEAREST WELL It FOUNDATION R PROPERTY LME it <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft Z <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LME R <br /> SEEPAGE PITS NUMBER J WIDTH R DEPTH It <br /> DISTANCE TO NEAREST WELL y�iSs it FOUNDATION R PROPERTY LINE Ste - ft <br /> 1 HEREBY CERTIFY THAT 1 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 /> MINIMUM2 HOUR VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)957-7697 <br /> SIGNED � — TITLE DATE <br /> t 1 <br /> Z , --14 <br /> lit1 I <br /> _S, m _ <br /> kul <br /> -i' 44 <br /> / <br /> - 9 A L <br /> DEA7 N <br /> TTR <br /> DEPARTMENT U E�.QJNLY <br /> Application Accepted By Date f D f"I Q Area Employee iD# <br /> Final Inspection By Date Z6 11 SPECIAL PERMIT-Approved by / f <br /> Character of Soil to De of 3 Ft: PIV ump it Character: <br /> COMMENTS OLL a rD E-Co eQ <br /> X'e' k/..w rt- / �Ll L�Di�esiP /yL / /� ori / i' - B mi <br /> PE SC Received Check# Amount Date Permit/ Invoice# Permit lD# <br /> Code INFO B as Remitted Service Request# <br /> 'f2 16 25-o ffZ --ss, q i <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 1222/2003 <br />