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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202.(209)4683420 <br /> PION-REFUNDABLE PERMIT rJ� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JGBAODRESS 4r.-,Fc W . HwN- IZ cNYZP_ L-0D I (_� 957.•{2 H <br /> (Z <br /> CROSS STREET _A7 APN 055--((00—S0 <br /> • PARCELSUM 3&-A-c <br /> OWNER NAME AVe-u-AELToAyjb WINEM <br /> PHONE �3pColr-(�+T"3F� �^ <br /> OWNERADDRESS *yO O w• rf W y° 1' 1L� "� CItY/STATE/LP yLO�I -c 7 O , ~142 <br /> CONTRACTOR LIFE'DFret; LTCOEAj1n�AJM�L PHONE 3%4-031-5- <br /> CONTRACTOR <br /> % 9`031.5— <br /> CONTRACTOR ADDRESS 4o -+ W-oAy--. $"T- CnY/STATETP LJDI CA (��-•{� <br /> LICENSE QC42 QC46 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOORAPHICALINFORMATION: Coordinates X Y <br /> PERCTEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNEDIALTERNATVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNnMC NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITYgal #OFCOMPARTMENTs <br /> ❑ GREASETRAP TYPEIMFG CAPACITY <br /> gel #OF COMPARTMENTS <br /> DISTANCETONEAREST: WELL It FOUNDATION it PR:PERTYLINE ft <br /> Cl LIFTSTATION SIZE TYPE OF PUMP O PKGTXPLANT O SAND OILSEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHINGCHAMBERS #OFLINBa LENGTHOFUNES ft <br /> DISTANCE TO NEAREST WELLR FOUNDATION . ft PROPERTY LINE it <br /> ❑ FILTER BED WIDTH it LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE it <br /> ❑ MOUNDED WIDTH ft LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELLIt FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE It <br /> Cl DISPOSAL PONDS WIDTH it LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY UNE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH - DEPTH It <br /> • DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNW ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATONS OF SAN JOAQUIN COUNTY. <br /> INIMUM 3050 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 �1 <br /> SIGNED �'�� TITLELONSYLTyt wT>- DATE 9 "/ <br /> S�3s fid ����® <br /> I.----Ar=. .- .LLS - _ - 0 1 <br /> J <br /> -_-- - 40' RAY RIND — y/ <br /> DEPARTMENT US ONL [[ �//y^* ✓/•-iF�\ <br /> Application Accepted By Date`�L 7 Ama / 1 1 / Employee ID# <br /> Final Inspection By Date ❑ SPEE;IAAL PERMIT-Approvetl by <br /> Character of Soil to Depth of 3 FC Pit/Sump Soil Chamcter. <br /> COMMENTS <br /> • PE SC Rec.Wetl Chsc AmountpermlU InvoiceFerrol[lop <br /> Cotle INFO ash Remitted , Da Service Ra nest# # <br /> � <br /> 4=-0t, ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />