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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENYVIONMENTAL HEALTH DEPARTMENT 1868E HATELTONAV NUE-STOCKIONCA95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS 501D pE/�. EIGHT VYI I L E 2D. c Wz,, s`[e>c,,l/J >�2QL X11 <br /> CROSS STREET 1'YW /-I APN 02 0 +0— 10 PARCEL SDE e <br /> —7 <br /> �. OWNER NAME GJR-PQE ET SI NFr FF E�o /NDF¢J IT ?o02�P oxE c- Q 96 i <br /> OWHERAODRESS 23og Tliol rife. Swr-e. A pTwgTATIzPP rV,I 00997bGR q AV 4 <br /> coNTRACTOR IIYC&Ar- C-£'OEn/Vl2ee/M[-ATT- -= PHONE 369-0'TJ <br /> 'fol- W. OAK ci. Cm.STATFjzF LODI CA CIS-Zil <br /> CONTRACTOR ADDRESS � <br /> LICENSE ❑OC42 ❑❑C416 OTHER Nummea EfrnRATIONDATE <br /> WATER TABLE DEPTH: It GEOGRAPHICALINFORMATON: COorDIOa166 X Y <br /> PERC TEST I F BUILDING PERMIT# LAND USE APPLICATION# OL7 �z 6 D C <br /> TYPE OF WORK: ❑ NEW 61STALLAT]oN 0 REPAINADOmON ❑ ENGINEER NEO/ALTEANATNE <br /> D REPLACEMENT ❑ CUT-0FSERVMESEPTICSYSTFAI ❑ DE5RNC110N <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COYMFACIFL ❑ OTHER <br /> NUMBFA OF LINNG UNM: NUMBEROFBEDROOMS: NUMSEROFEMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPAO gal #OFCOMPAIT ENTS <br /> ❑ GREASE TRAP TYPFJNIFG CAPACITY gal #OFCOMPARTMENTS <br /> DISTANCETONEAREST: WELL ft FOUNOATION It PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKGTXPLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES 0 LEACHING CHAMBERS #OF LINES LENGTH OF LINES It <br /> DISTANCETO NEMEST KOLL It Fouic Tmch ft PROPERTY UNE It <br /> ❑ FILTER BED WIDTH R LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE It <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCETONEAREST WELL ft FociHmmDN ft PROPERTY UNE ft <br /> ❑ SUMPS Iii ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WEU. ft FoUNoAT10M ft PROPERTY UNE ft <br /> ❑ DISPOSALPONDS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST 4 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS N.NBatl WIDTH ft DEPTH It <br /> DISTANCETONIuaE KRLL ft FCUNOAMON ft PROPERTY UNE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUAI HOURADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2091953-769 <br /> SIGNED TITLE LOALS✓—TAIVi DATE ?-7-0-1� <br /> R c�EST <br /> OgQU1N <br /> of 4,9 q/Nry <br /> INTI <br /> n. DEPARTMENTU NL <br /> Application Accepted By - Date ZO f Area 91� Employee ID# <br /> Final Inspection By Dale ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 R: PRISump Sol]Character: <br /> COMMENTS <br /> PE SCReceived ChM"f AmountDate PermW Nvebel PermN la <br /> Code INBy, Remitted! Serwlca,Req..ti <br /> K52,12 i2 2 6,11 S 00 p <br /> 42A1 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4Dau <br />