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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> `SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS3S/ \YILw�./ .�/ to <br /> // � CITY/ZI <br /> /P <br /> � <br /> CROSS STREET ��y{`S APN (0 0:) ( <-LJ I3 PARCELSIZE 10 eS <br /> OWNERNAME �� FI PHONE 72k- 571,& <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR l jJ� / �� /1fjG PHONE <br /> CONTRACTOR ADDRESS�1>1Jp �ee I fm-,e CITY/STATE/ZIP 4r} - <br /> LICENSE 42 ❑C-36 OTHER NUMBER--q52EXPIRATION DATE 1, ` <br /> �WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> i❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED ALTERNATIVE <br /> REPLACEMENT ❑ DESTRUCTION <br /> L,INSTALLATION WILL SERVE: MRESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> TIBJ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:_ _ 3 NUMBER OF EMPLOYEES: (' A <br /> SEPTIC TANK TYPE/MFG 1?4eZ/ CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL 5-0, R FOUNDATION ft PROPERTY LINE /49 d' ft <br /> L❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES j ft <br /> LDISTANCE TO NEAREST WELL GS" R FOUNDATION ft PROPERTY LINE as R <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> L❑ MOUNDED WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH R <br /> p,1 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Vl SEEPAGE PITS wIDrx1r ft LENGTH ft DEPTH <br /> LDISTANCE TO NEAREST WELL Jr/J R FOUNDATION ?O ft PROPERTY LINE R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> V. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE �xsx•� DATE X0113 <br /> I <br /> Js <br /> r <br /> a57 <br /> av/ awl <br /> r <br /> OuIt, G s <br /> BL N pL D 1 <br /> NN <br /> I, <br />