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�1 <br /> 1 _F <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 F,WEBER AVE-3"°FL-STOCKTON CA 45202 - (209)468-3426 <br /> ,f NON-REFUNDABLE PERMIT1 ., rCALL(209)951-+7f697 F1O�R• IN'SPECTION'S EXPIRES 1 YEAR FROM DATE ISSUED <br /> IY YI JOB ADDRESS i.) w- .)� 4F Y . ),i 11�L 4: I 1 r CITYf7.IP I ., `— 5_-f i <br /> k <br /> CROSSSTREETAPN"',i.- 5 "'�, <br /> '� PARCEL SIZE -�- <br /> OWNER NAME 4%i°.r, -1 �� ✓cs,s -1� C. 1= ''i :_§.; PHONe i� 1� .r (� (c'`(c' <br /> { f OWNER ADDRESS - µ CITYISTATEIZIP <br /> .l <br /> CONTRACTOR 'S fir,~f PHONE <br /> I CONTRACTOR ADDRESS °;0 7 1 •" •=^%S A/ h �"a s"-`-1 CITVfSTATVZIP L. '�_-5.., ( .f' -IN <br /> 1 <br /> j LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATfON DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X ]' <br />{ UO PERCTEST H a BUILDINGPERMIT# LA ND U SE APPLICATION# <br /> I TYPE OF WORK: 11 NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGN F.D IAIA ERNATIVE <br /> ❑ REPLACEMENT O DES1'RUC'r1ON <br /> 1 INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> R^� <br /> r ❑ SEPTIC TANK TYPE/MFO CAPACITY gal 4 OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG 'CAPACITY <br /> gal HOF COhIPART.ViI NTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL 11 FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> D LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO N'EARE51' WELL H FOUNDATION B PROPERTY LINE 6 <br /> Q FILTER BED WIDTH ft LENGTH - R DEPTH ft <br /> M DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE tl <br /> i Q MOUNDED WIDTH It LENGTH R DEPTH fl <br /> DISTANCE TO NEAREST WELL R FOUNDATION IT PROPERTY LINE it❑ SUMPS WIDTH R LENGTH R DEPTH ft <br /> i DISTANCE TO NEAREST WELL tt FOUNDATION IT PROPERTY LINE 0 <br /> i ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH FL <br /> DISTANCE TO NEAREST WELL it FOUNDATION IT PROPERTY LINE tl <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH 3 <br /> DISTANCE.TO NEAREST WELL ft FOUNDATION h PROPERTY LINE it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANU THE WORK WILL BE DONE IN ACCORDANCE WITH SAN.IOAQUIN COUNTY <br />! ORDINANCES,STATE.LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 26 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL L09}957.7697 <br /> tS `' y <br /> �1 SIGNED Ld - - ?�- '�'` `` -�--t / <br /> ` .�..w _ ..�� TITLE� ..i. DATE i �- <br /> f!` ; V / <br /> F7 1 <br /> i _ I <br /> 1 1 rY 1 <br /> 1 i <br /> Fit <br /> �1 1 ` /v DEPARTMENT USE ONLY u� <br /> # , Application Accepted By ---1�-ii' ! l �1' -, pate /���i Arra Employee[Do <br /> T- Final Inspection By Dale ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PitlSump Sail Character: <br />�h COMMENTS <br /> PE SC Received Check#1-' Amount Permit/ <br /> Date Invoke Permit IDH <br /> Code rNFO <br /> Rv "-Cash Remitted ScrOcc Re uest 4 <br /> 42A2-[)OI ONSD E V,'ASTF%VATFR PFR MIT <br /> ._. 1212212001 _ <br />