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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 209 961-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rrn <br /> JOB ADDRESS A I CITY/ZIP <br /> CROSS IREET COA(-,,:;iAPN �3/'1 I I 1 n�6 3 PARCEL SITED�67 Q <br /> OWNER NAME <br /> QgU e.e N PHONE <br /> OWNER ADDRXSS S4�[ _C�• �L/ S te'y1-L�/L CITY/STATEMP <br /> CONTRACTOR Pxol'Te <br /> CONTRACTORADDRESS CITY/STATErZJP Z ' <br /> LICENSE ❑CA2 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DErrH:_ R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ (TION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENTb006 ❑ DESTRUCTION <br /> r <br /> INSTALLA71ON WILL SERVE: FSIDENCE ❑ COMMERCIAL ❑ OTHER <br /> — <br /> NUMBER OFLIVING UNITS: I NUMBER OF BEDROOMS: U NUMBER.OFEMPLOYEEs: <br /> ❑ SEPTICTANK TYPE/MFG_aj, CAPACITY } (O(D gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION R PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENOTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> FILTER BED WIDTH :3 a ft LENGTH 5-0 _R DEPTH f zIr ft + <br /> DISTANCE TO NEAREST WELL_�^R FOUNDATION 10 ft PROPERTY LINE S ft <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 /> DISTANCETO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH _ ft DEPTH ft <br /> DISTANCE TO NEAREST WELL _R FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NuMBcn, WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FCiUNDATION R PROPERTY LINE III <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUI%ED FOR INSPECTIONS-PLEASE CALL(209)953-76-)7 <br /> SIGNED C�C► .�� TITLE 'J� dLt.va, �f.ter 7 DATE _1_ Q� <br /> i mm •I®io o�r�I uca <br /> ruRs�sna �� <br /> .I.. �-r <br /> ------------- <br /> •WA ;' ! - rd anlmrlwm o�ovawui <br /> v� --- <br /> !J <br /> - t Ira ' sa anFT <br /> r <br /> SOX", <br /> H 1 rI� <br /> f ♦r 7y 'i v a Rai AREA <br /> I. <br /> 'I ti <br /> Y � o <br /> O � `_ �i�enogm�elo .p arc. �■{ --- -- .._i_/_. <br /> to <br /> tDa I�IMWTE oc <br /> ' rsnc�-ritsv ti <br /> ---------- x MEA(FLLTM Bt: S 1 I $ oreA <br /> a PINlirTraosaeatRa r.msr PAYMEc,. <br /> ---- a MAR 1 9 2i il+ <br /> -- --..sr- - —-_` - ---- <br /> as w sn� SMI JOAQUIN CC`.-'Ai <br /> FT-TENVIRONM <br /> DEPARTMENT USE L �7 / <br /> AppllcationAmrpted Q /A. Employee ID NO <br /> Final laapec H Date / ❑ SPECIAL PERMIT-Approved by <br /> Cha meter of Soil to Depth 3 Ft: Ptt/Sump Soil Character: <br /> COMMENTS ts <br /> ;--B, epi z-�, , p- - - <br /> PE SC Reeelved a Amount pate Invoke PerINtIDVI <br /> Crj,ode INFO B As Remixed Service ueat# <br /> 2r b <br /> S/per ii1- rwi1 --r�— c.C/ <br />