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ONSITE WASTEWATER TREATMENT SYSTEM PERMMCANNED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AvE-3R°FL-STOCKTONCA95202-(209)468-3420 <br /> }.+ NON-REFUNDABLE P RMIT CALL(2091953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB At1DR£55 KLL//++llt^ /�C'- �EC�,1,TIYIZAIP r�• 1c///���hhht/`�� 0 <br /> 1 <br /> CROSS STREET C/[-' 1 ` APN E�Jt n Ft'[l"4_, PARCEL SIZES <br /> III m <br /> OWNERNAME /�/I(yL'1�L/'y-�GKI : S 1 PHONE-111-79YJf.++���./.^� <br /> OWNERADURM 2212MAI CrfY/STATEIZIP _ (C,%��-!A _ <br /> CONTRACTOR Q'A - 1 PHONE ! <br /> CONTRACTOR ADDRESS CITYISTATPJZIP <br /> LICENSE -C-42 aC-36 OTHER NUMBER E%PIRATIONDATE <br /> �d WATERTARLEDEPITI: ft GEOGRAPHICAL INFORMATION: Ceordinales X Y <br /> i ❑ PERC TEST # I BUILDING PERMIT# D LAND USE APPLICATION It t�7 <br /> TYPE OF WORK: A NEWINSTALLATION LI REPAIWADDITION ❑ ENGINEERDRSIGNEDIALTERNATIVE <br /> O REPLACEMENT ❑ DESTRUCTIONrlt _ <br /> INSTALLATION WILL SERVE: ry❑ RESIDENCE ❑ COMMERCIAL //� OTHE <br /> 4u Our- <br /> t NUMBER OFLIYINGUNITS: 1 NVMBER OF BEDROOMS: l NUMBER OF EMPLOYEES: <br /> I <br /> 1 SEPTICTANK TYPFJMPO 9' C L CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASE TkAP TYPFJMFG CAPACITY gal #OF COMPARTMENTS <br /> L3PKG TX PLANT DFSTANCETONEAREST: WELL ft FOUNDATION ft PROPERTY LINE fl <br /> I p❑n LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM)) <br /> ♦I%' LEACH LINES LEACHING CHAMBERS 136 #OF LINES LENGTH OF LINES 40, <br /> 1 V ft <br /> DISTANCE TO NEAREST WELL 2150+ R FOUNDATION R PROPERTY LINE .J R <br /> ❑ FILTER BED WIDTH R LENGTH R DEPTH R <br /> [[[ ! DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ MOUNDED WIDTN ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> 1❑ SUMPS Wwrm R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LME ft <br /> i� ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> I l SEEPAGE PITS Nvmluot�w1DTR _� R DEPTH fl <br /> r[ 1 DISTANCE TO NEAREST WELL �ft FOUNDATION_. 0_ R PROPERTY LME fl <br /> # 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDFNANCM STATE LAWS AND RULES ANA REGULATIONS OF SAN JOAQUIN COUNTY. <br /> I <br /> ORL-d- <br /> M� FORT1IPL 29)953-DV15 <br /> SIGNED ATV � <br /> f <br /> E 4 <br /> f <br /> SN O4IN O <br /> ns <br /> T E <br /> TZ <br /> E <br /> � f <br /> I� <br /> 4 <br /> o' <br /> t ' ART e T E LY <br /> Application Accepted Date Area Employee IDR <br /> {Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> �1 <br /> character of Soil to➢e of 3 Ft: [!Sump SoU Charecter: <br /> L J COMMENTS f CT l ei <br /> I <br /> F PE SC Received het Amount Date Permit) <br /> Code INFO 8 Cash Remitted Service Re uest# IRvoice# Permit IDR <br /> I 1 '2, \ DS 500 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 121 n003 _ <br /> i <br /> I <br /> 4 <br />