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1 `- 0� ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3X0 FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-wA (7697 FOR INSPECTIONS D�EXPIRE(�S I YEAR FROM DATE ISSUED <br /> JOB ADDRESS ,,[[ I P- ^ !CITY/ZIP p ri'lot <br /> Ayw I <br /> CROSS STREET /11�"n �'� �� APN LSo I CIO'6n-`'' `�10 PARCEL SIZE-1'5�G�+S o <br /> 9 <br /> OWNER NAME P� e ?)01c-b4V, PHONE(10C41 33-3-43111 <br /> OWNER ADDRESS 19"tS 3 S MPAL 617 WNYc CITVISTATE/ZIP IYc m .21.�t1i ciss n(V <br /> CONTRACTOR NIA PHONE J�+�3- <br /> CON rRACTOR <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> r0FERC TEST # L BUILDING PERMIT# LAND USE APPLICATION# 0 0 0 21 <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/MFC CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIzE TYPEOP PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES It <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ FILTER BED WIDrx ft LENGTH It DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE R Q <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft C <br /> DISTANCETONEAREST WELL ft FOUNDATION R PROPERTY LIVE ft <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH It i <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft 1 <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> DISTANCETONEAREST WELL R FOUNDATION ft PROPERTY LME R <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THISAPPLICATION 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 REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9,53J7Q97 C <br /> SIGNED TITLE /"_e. C. 1Hi-a+--' L• DATE <br /> .1ruww M, <br /> p a KIEltO KS 1 � <br /> _ PARCEL "1" sy II <br /> � P s <br /> macserw. <br /> § <br /> •onw wouM no•- � as <br /> wnra>nrw ,�y>,. <br /> w.tuw. •�K v <br /> 1111, 11 1111H++ <br /> DEPARTMENT UW ON Y .S <br /> Application Accepted By _ Date vc— Area Employee ID# Co <br /> Final <br /> Final Inspection By Date ® 0; SPECIAL PERMIT-Approved by <br /> Character otSoe W� hof 3 Ft: P' '�--'p Sori Character. <br /> COMMENTS <br /> PE SC Received ec Amount Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted DatePermit/ <br /> Reavest# <br /> 4f=--ZZ, TIM93.oc I O p <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> I2l2272003 <br />