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ONSITE WASTEWATER�EATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304EWEBERAVE-3POPL-STOCKTONCA95202 - 468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> HuvUL:ItC,46 k0d- C—lZIP m <br /> JOB ADDRE3E 11 jy� �J �'�� ��(•� /� /�/� L <br /> CROSS STREET �kzl%% c 1 I'Sr�� ^ APN �WJ-Dp. ITT PARLELSIZE 9 <br /> OWNER NAME Ir IkI-E 1�`_ _���3�L PHONE • <br /> OWNER ADDRESS CITY/$TATFILIP �( <br /> CONTRACTOR I PRONE 1' G <br /> CONTRALTO ADD )'J CITY/STATE/ZIP I V, <br /> L 3 ❑C-C2 ❑C-S6 OTNE0. NUMBER EXPIRATIONDATE f <br /> WATER TABLE DEPTH: R GEOGRAPHICALINFORMATION: COOrdinateB X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION#RA-_CA_- T <br /> TWE OF WORK: ❑ NEW INSTALLATION ❑ REPAIWADDITION O ENGINEER DESIGNED/ALTERNATIVE <br /> O REPLACEMENT ❑ DESTRUCTION 1 <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBEROFLIVINGUNDS' NUMBER OF BEDROOMS: NUMBER OF EMPIAYEEE: <br /> ❑ SEPTIC TANK TYPFIMFG CAPACITY Ed #OF COMPARTMENTS <br /> ❑ GREASE TRAP TVPFJMFG CAPACITY P1 #OF COMPARTMENTS �- <br /> ❑ PKG TX PLANT DISTANCETONEARESf: WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ LIFT STATION sm TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSEDSYSTEM) 4 <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS OOF LINES LENGTH OF LINES ft <br /> DISTANCETONEAREST WELL ft FOUNDATION IT PROPERTY LINE R <br /> ❑ FILTER BED W'. ft LENGTH R DEPTH ft T <br /> DISTANCE TO NEAREST WELL It FOUNDATION R PROPERTY LINE fl <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH R(1 <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE r <br /> ❑ sumps WIDTH R LENGTH ft DEPTH ft <br /> DISTANCETONFARES'1' WELL 6 FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTR ft LENGTH R DEPTH fl <br /> DDTANCETONEAREST WILL R FOUNDATION R PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMeEa Wm7N ft DEPTH fl <br /> DISTANCETO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM H HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(20N)953-7697 <br /> SIGNED '' "f//� '� 7 TITLE DATE i /I` I <br /> pAY <br /> RE <br /> pEC 4 <br /> 'OSpNdon N U <br /> wr <br /> 11565.11' F nHONOA EN <br /> 472.33' 344.21' moo <br /> A <br /> �15G Z, i�R c3& <br /> A 9 A <br /> O3, 9'+c <br /> r 9'c <br /> 15 .41' 48102' 502 74' 5 2 - <br /> 40WULaread Pd <br /> DEPARTMENT US ONL S <br /> Application Accepted By Date (2 f Area Z-I �7 Employee ID# i u Sy /9y <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of Ft: Pit/Sump.Soil Character: <br /> COMMENTS <br /> PE SC Received CM1akp/ Amount PermlU <br /> Code INFO B e Remitted Uvte SerWce Re Dea[# Invoice# PerMtID# <br /> 42.az- 521 1 Z�c I t7c)121 13r2.dd <br /> OJO-0pl ONSITE WASTEWATER PERMIT <br /> ILLJrz003 <br />