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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQVIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3R°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL20F9� 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I 7' LI QC��T L( R ;A CITY/ZIP GT A L-T � <br /> CROSS STREET AC LX-V IJV�- 00-013-- t <br /> APN I PARCEL SIZE � L6� �C � <br /> OWNER NAME AG(---IGU LI VliAL. H< LAI�161 LL-.0 PHONE 2--',oi-6ik- L1 ® <br /> 6oI <br /> OWNER ADDRESS 60l CA&LSo.j �KLJ �hLLril CITY/STATE/ZIPM1-Jw<%. - yi A' MM SS305 <br /> CONTRACTOR 'c 1,.t ._aG L)!HCS LLC PHONE 2- 0"- 61LI <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gel #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LME R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft — <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R - <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft i <br /> ❑ DISPOSALPONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT I 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 /> �,��� MIINNIIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED -y% � �. TITLE A&—fT O L✓00L DATE L - 1 3-' p S <br /> A 3�j <br /> S <br />