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ONSITE WAST 'VATER TREATMENT SYSTT- ( PERMIT <br /> SAN J'AQUIN COUNTY ENVIRONMENTAL HEALTH DE!!AwRTMENT 304 E WEBER AYl'3""FL-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 ( _ ��P 1 CITY/ZIP —( f <br /> CROSS STREET 0�/ / /qtL APN //-'jo CC(— 055(/' 'PA/RCELSIZE <br /> ( ` V <br /> OWNER NAME ---r4�+`T�4'-=- / 1 /� 7 I 1 PITONS <br /> c� `- b CITY/STATE/ZIP <br /> OWNER ADDRESS / �� t7 ` ra,:n Q � ( <br /> CONTRACTOR - I PHONE 2.7I - t ( <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: - ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> O PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NifW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> 1 <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 _r\ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS -� <br /> r� <br /> ❑ PKC Tx PLANT DISTANCF.'r0 NEAREST: WELL 11 FOUNDATION 11 PROPERrY LINT: <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft n <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE fl <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ti ^^�� <br /> DISTANCE TO NEAREST WELL N 'I ON fl PROPFRIY LINE Il 1� <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft OUNDATION fl PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft NOT ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPS2'Y 1 <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY E ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl 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 <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 'MfNIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE 1 .G. h < DATE <br /> IRECEIVED <br /> 2005 <br /> UNTY <br /> N IR N E Al- <br /> HE JL1H DEP'kRIMENT <br /> i, — <br /> 7 <br /> 1 <br /> /� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By A 71 / Date J �/Tl.� ��7 Area �' �! Employee ID# y <br /> J <br /> Final Inspection By i. Date 7 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: ) �L� <br /> COMMENTS = 'IlC� f — CcV"�l2 C1�c`Jt "CIeVt�S 1N" S 1�.4r� /aA+:a t'2o1='4 vt '/v 7o LC 3'!�iv-�5 Aiv7 t <br /> 4C4 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Bv ash Remitted Service Request# <br /> l/7 Sc 7, 15 'Jo— - k'C0/ -aC &Z 3-43 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12122/2003 <br />