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ONSITE WASTEWATER2EATMENT SYSTEM PERMIT <br /> FN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"'FL-STOCKTON CA 95202)468-3420 <br /> rNRABLE E MIT CALL(209)9:]=7697 F R INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> _ w <br /> !/ 1r � -� r �// CITYIZIP11 )lrw`�1nq �"Ir`� APN ! -_0 71�U 3(J' PARCELS12E!4 lir PHONE <br /> ! CITYlSTA'fElZIP I <br /> 1 r��� V16 - PHONE gG �`- 7 7D 76 / <br /> )NTRACPUR <br /> l -I.UNTRr <br /> ACTOR ADDRESS `y u Y. (fit r L: CITY/STATEIZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> ATER TABLE DEPTH: fl GEOGRAPHICAL INFORMATION: Coordinates X Y I -, <br /> Mr FERC TEST(SJ NUMBER LAND USE APPLICATION# I �] <br /> 1� <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIQNEDfALTERNATIVE <br />` ❑ REPLACEMENT ❑ DESTRUCTION <br /> 1! e—I <br /> 1STALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL El OTHER <br /> f�f El NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NOMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> I ! CREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> PKGTXPLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE - <br /> c� 7— <br /> ❑ LIFT STATION SIZE_ TYPE OF PUMP Q SAND OIL SEPARATOR(ENCLOSED SYSTEM) ;0 <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES t7 <br /> DISTANCE TO NEAREST WELL fl POUNDATION fl PROPERTY L19E fl <br /> ❑ FILTER BED WIDTH fl LENGTH fl DEPTH fl <br /> DISTANCETONEAREST WELL ft FOUNDATION fl PKOPERTYLINE fl <br /> MOUNDED WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOIfNDAT1ON ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH fl LENGTH (i DEPTH ft ^ <br /> DISTANCE TO NEAREST WELL fl FOUNDATION fl PROPERTY LINE fl <br /> DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> N DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ SEEPAGE PITS WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION—ft PROPERTY LINE 1t <br /> +iEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANDTHE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> 3 ^ STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> ff / NI M 44 H+OUR ADVANCE NOTICE REQUIRED FOR INSP CTIQNS-PLF:ASL CALL.(209)953-76')-, <br /> _ <br /> tGNED t .✓€.l'I�C "" TITLEC: f C DATE <br /> 1 <br /> Al <br /> MX <br /> C. <br /> II �� <br /> s. <br /> 9 u <br /> P � <br /> v P <br /> Ce l (,C <br /> i <br /> DEPARTMENT PSE ONLY ' <br /> Application Accepted By Date l 1 OL/ Area EmpVoyee IDik <br /> 'nal Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> haracter of Soil to Depth of 3 Ft: Pit/Sump Soil Character; <br /> OMMENTS <br /> 1 PE SC Received '6heckHl` Amouat Permit! <br /> Date, Invoice 4 Permit ID# <br /> =,r.Code INFO 8 Cash Remitted i 1 Service Re-uest k <br /> A1001 ONSITE WASTEWATER PERMIT <br /> -rzn�az <br />