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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT '-On-, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3-FL-STOCKTON CA 957 )468-3420 <br /> NON-REFUNDABLE PERMIT CALL 20 -7697 FOR INSPECTIONS EXPIRES I YEAR F ATE IS[S,�UED <br /> / <br /> JOB ADDRESS CITY/ZIP 1i-�/Y�C * / � ! y <br /> CROSS STREET �yJ4n�� AAPN�06117/ �0-©� PARCEL./SIZE_ D <br /> Nyr <br /> OWNER NAME nptr FLr�� ZrfY�Z1� �'w��y�++Y LC- PHONE for <br /> OWNER ADDRESS +t(T��y� 1 CITY/STATF/ZIP I4f L <br /> CONTRACTOR �. ^ 1- PHONFZej 1 1�`v'I O <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP am 2 <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT#jW O / LAND USE APPLICATION# <br /> PA - <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGIN€ER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTAR <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: , / NUMBER OF EMPLOYEES: <br /> PTIC TANK TYPE/MF CAPACITY� I _ gal #OF COMPARTMENTS \ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY ! ,� gal #OF COMPARTMENTS N <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION (C/ ft PROPERTY LME J R <br /> ❑ LIFT STATION SIzE TvPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETo NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH R V 3 <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH <br /> DISTANCE To NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> I HEREBY CERTIFY E PREP RE THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> OR IN CE ATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 1 H <br /> ADVANCE NOTICE REQUIRED FOR INSPECC711ONS-PLEASE CALL(209)953-7697 <br /> SIGNED 'Ales. TITLE / DATE E/ f <br /> O1.6 <br /> J1 I L or <br /> CIL I <br /> e e <br /> a <br /> DEA T US O L <br /> Application Accepted Date / 40Area-2�2 Employee ID# <br /> Final Inspection B !�- - Date �/G S ❑ SPECI L PERMIT-App`A VIA <br /> Character of Soil to De th of 3 Ft: v Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check# Amount Date PermiU Dice# !'T// EPq <br /> Code Ingo ash Remitted Service Re uest# <br /> 42-02-001 <br /> ONSITE W <br /> 12122/2003 C -+ -� �c ".R- C /� .�(,/..�G,�L ',✓ �/- `�I c•��S <br />