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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPMTMENT WO E MAIN STREET-STOCKTON CA 95202-(209)4693420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOSAODRESS 313 4 S yJE C-sfLOaY✓1 S IZ.p c'm/zp .r L <br /> CROSS STREET�. 1NIC��yoh1-�a.-�Uy� yJ� APN 2-0-;1-7-'po "-CIT /IPMQ�EyL sQE��QJ�$C.i y> <br /> • OWNERNAME 61JENJ E �btj;L J -Le:" je� � ,/PHONE p5?4-- <br /> OWNERADORESS1 ,I P(p 5� �1p �1 Y✓ Cm/STATETPQ�_/�oAKPPtAr TC1 A '103(¢1 G <br /> CONTRACTOR L14 v"I' CNV-- OQ�J���yU�FEN7I'fl� PXONE $I 1 <br /> CoxTRAeroR ADDRESS �-1 W- OrCK 4T. C"ISTATEMP (.DDT LR �T'2-L4-O <br /> Um E QC42 QC36 OTHER NUMBER <br /> E%PIRAnON DATE <br /> WATER TABLE DETTH: fl GEQGRAPXICAL IxvORMAnox: Coordinates X Y <br /> PERC TEST # 2 BUILDING PERMIT# LAND USE APPLICATION# PTI <br /> TYPE OF WORK: D 14MINSTALIATON ❑ REPNPNADGITION ❑ ENGINEERDESIGNEDIALTERNATIVE <br /> ❑ REPLAcwSNT 0 DESMULIMON <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL O OTHER <br /> NUMBER OF NG UNM: NUMBEROFSEDRWMS: <br /> NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPFJMFG CAPACm gal #OFCOMPMTMENT4 <br /> ❑ GREASE TRAP TYFWMFG CAPACm gai #OF COMPMTMENTS <br /> DmANCETONEAREST: WELL ft FOUNDATION ft PNopsR LINE ft <br /> 13LIFT STATION SMTYPE OF PUMP 0 PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OFLINEs LENGTHOFLINEB It <br /> DISTMCEWNEAREST WELL It FOUNDATION R PROPERTY LINE R <br /> ❑ FILTERBED W. ft LENGTH ft <br /> DEPTH ft <br /> DISTMCETO M <br /> NEEST WELL R FOUNDATION ft PROPERTYLINE ft <br /> 01 MOUNDED 4WOTH R LENGTH ft DEPTH R <br /> DmTANCETONEEST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS M <br /> MOM R LENGTH ft DEPTH ft <br /> DISTIWCEMNEME3T WEl1 ft FOUNDATION ft PROPERTY LINE ft <br /> 13 DISPOSAL PONDS WmTN ft LENGTH ft DEPTH fi <br /> DISTANCEMNEAREST WELL ft FOUNDATION fl FROPERTV LINE R <br /> ❑ SEEPAGE PITS NUMBER "m R DEPTH jl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERtt LINE R <br /> 1HEREBY CERTIFYTHAT HAVE PREPARED THIS MPLICATION AND ME WORKWILL BE DONE IN ACCORDMCE WRIT SM JOAQUIN COUNTYCROINMCES, <br /> • STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PL EASE CALL(209)952-7697 <br /> SIGNED TITLE LO MS✓L:T-A /- DATE 4.1'-11-I(D <br /> _ ❑ <br /> I <br /> I <br /> eow T�� <br /> I <br /> • a <br /> - c�a� <br /> e r.m 7 <br /> DEPARTMENTU ON Y/ <br /> Appllcatlon Atteptetl Dam 6 Area Employee ID#Td /U D U JOS <br /> ChWhaCtal OfSn By Dale ❑ SPECI LP MIT-Appiovedby <br /> Chander of Soil to Depth Of 2 FY Pk/Sump 9011 Character. <br /> COMMENTS <br /> PE SC ReOehred he Amount Code INFO itted Daft Invoice#RemPermit ID# <br /> 42_Z2.. Zj 1 +'(Ai _ Servtm Re uest# <br /> -aiGj 5R007 "3G(5 <br /> tplppT ONSITE WPSTEWATER TRTMM9YSTEM PERMIT <br />