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f <br /> ONSITE WASTEWATER TREATI,.,, NT SYSTEM PERMIT <br /> J SAN JOAQLIN 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 INSPECTIONA EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS J L3 <br /> _ CiTY171P <br /> ± CROSSSTREET APN `-;� <br /> - fvim_� ! 3/, ,k,_ PARCEL SIZE._ <br /> OWNER NAME � �a / 1�� PHONE <br /> OWNERADDRESS CITYISTATEIZFP <br /> CONTRACTOR <br /> I --_�/_!i LNW PHONE / j <br /> CONTRACTOR ADDRESS J 1.J CITYISTATE/ZrP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> 1 <br /> F ; WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X y <br /> Ft ❑ PERC TEST(S) NUMBER LAND USE APPLICATION N <br /> + TYPE OF WORK: ❑ NEW INSTALLATION 40 REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> I+ ❑ REPLACEMENT ❑ DESTRUCTION <br /> I INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> 111, NUMBER OF LlVINC UN]TS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES= <br /> 1 �' ❑ SEPTICTANK TYPEIMFG CAPACITY gal #OFCO.YIPARTMENTS <br /> 1 ❑ GREASE TRAP TYPEIMFG CAPACITY gal 4 OF COMPARTMENTS <br /> Il � L2 PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION <br /> ft PROPERTY LINE }) <br /> ❑ <br /> LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> F ❑ LEACH LINES C3 LEACHING CHAMBERS #OF LINES <br /> F` <br /> LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION�] / fl PROPERTY LINEI[ <br /> }FILTER BED WIDTH L:R LENGTH_ ,S D R DEPTH I R <br /> i DISTANCETO NEAREST WELL ,s"y' R FOUNDATION -3J R PROPERTYUNE zO t _ R <br /> ❑ MOUNDED WIDTH R LENGTH <br /> R DEPTH it <br /> t DISTANCE TO NEAREST WELL <br /> fl FOUNDATION_ft PROPERTY LINE }) ' <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH R <br /> I ` DISTANCETO NEAREST WELL ft FOUNDATION R PROPERTY LINE (t ; <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH <br /> j <br /> 'DISTANCE TO NEAREST WELL R FOUNDATION tY PROPERTY LINE R <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH A DEPTH ` <br /> R i <br /> EDISTANCE TO NEAREST WELL R FOUNDATION fi PROPERTY LINE fl I <br /> ]HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTI'ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24}LOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> - SIGNED <br /> F; TITLE DATE Z N <br /> f <br /> u <br /> 30 <br /> I E <br /> DEPARTMEN U E ONLY <br /> Application Accepted By ��-- - Date Area Employee ID#� <br /> F <br /> Penal Inspection By. �rim/K"!l (IDate L ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil Loth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS &/7_ 7f=Y � <br /> 1 <br /> � PE SC Receivedhe Amount Perm it <br /> Code INFO B ash Remitt d D to Service Re nest# Invoice# Per ID# <br /> -oD I <br /> ONSITE WASTEWATER PERMIT <br /> F <br />