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Or, ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-3"FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXP RES;YEAR FROM DATE ISSUED <br /> JOBADDRESS 1 IV JAG CITY/ZIP A� <br /> Q 6 9 O <br /> CROSS STREET /�N AIN C/D�V O`6 L� PARC^�EL SI'/E O <br /> OWNER NAME PHONE J .( <br /> OWNER ADDRESS CITY/STATF/ZIP 0c / <br /> 9 PHONE <br /> CONTRACTOR <br /> CONTIGCI'OR ADORE 54 CITY/STATE/ZIP <br /> LICENSE ❑C-02 ❑C 36 OT ER a UMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: �D R CEOGMPHICALINFORMATION: CDerdlOate6 X Y <br /> ❑ PERC TEST q BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAUVADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE \) <br /> ❑ REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ REMDENCe OMMERCIAL ❑ OTHER_ <br /> NVMBEROF LIVING UNITS: NVMBEROF BEDROOMS: NUMBEROFEMPLOYEES: <br /> ❑ SEPTIC TANK TYPE(MFG CAPACITY Sal If OFCOMPARTMENTS \ <br /> ❑ GREASE TRAP 7YPE1MFG CAPACITY, Sal #OFCOMPARTMENTS p� <br /> ❑ PKG TX PLANT DISTANCEMNEAREBT: WELL �7 R FOUNDATION_ R PROPERTYLINE It I \, <br /> .� LIFTSTATION SIZE TYPE OFPUMP > 1�,,c ) SAND OIL SEPARATOR(ENCLOSED SYSTEM) \ <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS I/#OFLINEE LENGTH OF LINES R �1 <br /> DISEANCETONEAREST WELL R FOUNDATION D PROPERTY LINE ft ... <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL R FOUNDATION H PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH ft <br /> DISTANCETONEARTST WELL ft FOUNDATION It PROPERTY LINE ft <br /> (3 SUMPS WIDTH ft LENGTH R DEPTH IT <br /> DISTANCETONEAREW WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH fl <br /> DISTANCLTONEAR6Sr WELL it FOUNDATION R PROPERTY LINE fl <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft <br /> DISTANCETONEAREST WELL ft FOUNDATION 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 <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> N UM S4 X01111 AD A)IC,ENNOOTTICE REQUI RED FOR I NSPECTTII'O.NS'-PLEASE CALL(209)953-7697 <br /> SIGNED,_-l,�y /�M'a'r�'+i�i TITLE W N 1/�Kl.�O 4 L DATE <br /> 1 <br /> 1 <br /> I <br /> E V O M NlAL <br /> F T <br /> • EPARTMENTU O -- � --- <br /> Applicatloa Accepted Detc Area Employ,I. <br /> It Final lnapection /.� Date L Zr4 eZ ❑ SPECIAL PERMIT-Approved by <br /> Character D(SoiIt.De haf3Ft: PIt7Sump Soil Character: <br /> COMMENTS Af!yy/ (IS(/�� � sOsllJi"'G.�hfNPbCaTVN1 GYlfflArL /�A I <br /> � )A�`tl,-L 2 aril srA•nlvAl r c-XKnw dg5erftC�A�cA- vsJ.s�� <br /> a*✓�Gs : e�'r Cbr1'�f�"Ld C ,2C� = l,C) o.eC <br /> PE SC R,Nved Ch,kl// Amount Date Permit/ Involceq Permit lDp <br /> Code INP. B /aa emitted Service Reamed 9 <br /> log tR b ) I <br />