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'01 ll� f � <br /> ONSITE WAST ,WATER TREATMENT SYST?'' VI PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH OWW RTMENT 304 E WEBER 3"'FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT �1 CALL(209)953-7097 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Ic��� Vt4 (�� � CITY//ZIP (+ 1 <br /> CROSS STREET (/U ry (� APN 0Z✓` ' —J O _ 3+ PARCEL SIZE o <br /> OWNER NAME L hJ •3�3� (y I <br /> /'� C -f� L PHONE <br /> OWNER ADDRESS '}`�•J� S��YI'UP��1 Il CITY/STATE/ZIP LV JI <br /> CONTRACTOR �� t�� PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> .S <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE r <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# C <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDIT ON ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT DESTRUCTION <br /> c <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 it <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft C:) <br /> .L 7 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH }t <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tt <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH }t <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH }t <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATEL WS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADV NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> 1 41111 1 <br /> r <br /> SA 1i J AC 11N COO] / <br /> p <br /> T PNKH <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Z Area ( Employee ID# 2 <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to DepA of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS TA <br /> PE SC Received heck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By ash Remitted Service Request# <br /> 2-L 3 S E E <br /> 42-01-001 <br /> 12/2/02 ONSITE WASTEWATER PERMIT <br />