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w <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY!ENVIRONMENTAL HEALTH DEPARTMENI 304 E WFDER AVE•3"FL-STOCKTON CA 95202 - (209)468-3-420 <br /> NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYlZIr <br /> _D �O/�� tin <br /> /� / t/ PARCPLSI7.E C <br /> CROSS STREET' _ �e- APN C•!� �--— � <br /> / R <br /> LJWNERNAME _Lr L' t0—, <br /> OWNER ADDRESS __ CrrV1STATFJZIP <br /> CONTRACTOR 1:��( PHONE <br /> CONTRACTOR ADDRESS' CITY/STATE/ZIP A 6 <br /> LICENSE 2 ❑C-36 OTHER NUMBER-2�EXPIRATION DATE��J <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y_ v' <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION#_ _ ._. <br /> TYPE OF WORK; ❑ NF.WINSTALLATION REPAHvADDITION ❑ ENCINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DE3rRLCT1ON w <br /> INSTALLATION WILL SERVE: IDENCE CI COMMERCIAL U OTHER_ _ <br /> NUMBER OF LIVING UNITS: _' NUMBER OF BEDROOMS' NUMBER OF EMPLOYEES: <br /> ❑ S£PTIC TANK TYPEIMFG_ CAPACITY gal 4 OF COMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gel 40FCOMPAR7MF.NTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION R PROPEKCY UNE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMPT ❑ SAND OIL.SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES At LEACHING CHAMBERS 15—!!'' #OF LINES �_ LENGTH OF LINES <br /> —V <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ FILTER BED WIDTH tl LENGTH It DEPTH ft <br /> DISTANCE'TO NEAREST WELL, ft FOUNDATION R PROPERTY LINE 11 <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH_. R <br /> DISI"ANCETO NEAREST WELL_ ft FOUNDATION_A PROPERTY LINE ft <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH _ ft <br /> DISTANCE.TO NEAREST WELL. R FOUNDATION_ R PROPERTY LINE 11 <br /> ❑ DISPOSAL PONDS WIDTH f2 LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATMN ft PROPERTY LINL� R <br /> Q� SEEPAGE PITS WIDTH I2 LE ft DEPTH \ ft <br /> DISTANCE.TO NEAREST WELL ft FOUNDATION /oft PROPERTY LINT J R <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE.LAWS AND RALES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR/A�DDVVANC NOTICE REQUIRED FOR INSPH.TIONS—PLEASE CALI.(209)9S3-7697 <br /> SIGNED /�/0� �`•� J^oi� ITLE ""?" ,__ DATE t� <br /> 29 11�4 <br /> C U TY <br /> IR N E <br /> Loa <br /> H H <br /> v <br /> 1 � <br /> DEPARTMENT USE ONLY 7 <br /> Application Accepted 3y _ __ _ Date D Arca Employee 1f1N_�> �^� <br /> Final Inspection Hy_ Date Z-2-11,11py ❑ SPECIAL PERMIT-Approved by _ 7 <br /> Character of Sail Su Dcpth or3 Ft: _ Pi Sump Soil Character: <br /> COMMENTS OjU_L,4 IQcU+�eQ / <br /> PE SC Received Check)$/ Amount ermil " <br /> Code INFO g as Remitted Date Service Request# Inv°Ice# Permit ID# <br /> 'Zdll) [ ss�8' po-' 1;11 <br /> r d 3 <br /> 42-01-001 ONSITE WASTEWATER PERMIT <br /> 12/2,'02 <br />