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ONSITE WASTEWATER TRFATMENT SYSTEM PERMIT <br /> SAN JOAQUIF COUNTY ENVIRONMENTAL HEALTH DEPARTMENT - - 304 E WEBER AVE-3""FL-STOCKTON CA 9$202 -(209)468-3420 <br /> NON-REFUWIPERMIT� ALL 209 53-769 r0- XPIRES 1 YEAR F OM 1 UED <br /> JOBADDRESS -I 'CITY/ZCROSS STREET 52 <br /> EAPN �..JW� PARCELSIZEA"ReMPA" <br /> OWNER NAME QGPxonEOWNERADDRECRY/STATE/ZIP CLJn/L A 9A <br /> T <br /> CONTRACTOR F \v PHONE <br /> CONTRACTOR ADDRESS - N CITY/STATE/ZIP <br /> LICENSE C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: D NEW INSTALLATION ❑ REPAIR/ADDITIONENCINEERDESICNED/ALTERNATIVE <br /> L) REPLACEMENT LI DESTRUCTION <br /> INSTALLATION WILL SERVE: I L17 RESIDENCE COMMERCIAL L3 OTHER <br /> NUMBER OF LIVI U <br /> NITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> S:x SEPTIC TAN 3 vPE/MFG 10CAPACITYiJC�(7 gal #OF COMPARTMENTS <br /> 13P TYPEGREASE TRA /MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL R rr+�FOUNDATION J©} ft PROPERTY LME__-�_ft r /I <br /> \v(JI <br /> LIFT STATIO SIit ZE TYPE OF PUM'60� ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEA WELL, ft FOUNDATION ft PROPERTY LME ft <br /> FILTER BED WIDTH_ �R LENGTHS �1lT)/RI DEPTH f ft <br /> DISTANCE To NEAREST WELL LCCL# R ppUNDATION _Jf 4 ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH_ft LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH_ R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE <br /> 1 HEREBY CERTIFY THAT 1 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 /> CM) 0 MIN IUM E OTIC <br /> E REQUIRED FOR IN NS-P Ll.(209)953-7697 Q n <br /> SIGNET ' TITL DATE <br /> 1 <br /> SET"cK <br /> PAYMENT <br /> r` <br /> DISTANCE FROM NEl1 RECEIVED <br /> • IODN*REPaR / <br /> AREA I _ <br /> / AUG 2 3 200`- <br /> f r T SAN JOAQUIN COUD-ENVIRONMENTAL' <br /> I I EALTH DE ART ES;, <br /> I Lei <br /> EN <br /> LEACNEIEL_ <br /> I� 14-BED CARE ,pry-p�µN>'..ESTC WELL <br /> SEE DETAIL_ I I FACILITY <br /> _ I DISTAHLE <br /> JFRON•HELL <br /> SEPTIC TANKS <br /> _ -- -- GARAGE 1 <br /> _ pJ L of o <br /> - <br /> AA]D <br /> `v.-SLWO <br /> 141 '� VCPPE <br /> CONTROL PANEL wI <br /> ALARRANDDEDICATED µABY AHD DECICATEDARCELUNE—� <br /> ELEPNONE LINE TELEPHONE LINE P <br /> OPTIOxµLOGTIONI (OPTIONµLOCATION( <br /> DEPARTN,ENT tj,sy ONLY - J <br /> Application Accepted By Dote Area 17 Employee ID# <br /> Final Inspection By <br /> Date — $ - ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dep of 3 Ft: Pit/Sum Soll Character: <br /> COMMENTS ' - <br /> ' h�.4-c.l p <br /> �S r C7/o v P RNJ z�rll —,/1 BUB Wly- <br /> tir <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B Remitted Date Invoice# Permit I1M <br /> Service m / # <br /> 02-001 <br /> '2'2003i'/1C>n ONS WASTEWATER PERMIT <br />