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r ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART..hiENT 304 E WEBER AVE-3"°FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(2-09 933-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOR ADDRESS26 C�1 CITYIZIP LA <br /> CROSS.STRErr <br /> AA©PN�,/+ S� ~ S P�A/R�C�EL`SI�TE <br /> a <br /> OWNERNAMELjj�g ( O' <br /> OWNERADDRESS %2= CFFYSTATE/ZIPslfy7— <br /> CONTRACTOR <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS t _ __ CTry/STATEIZIP 7 <br /> --�Iy <br /> LICENSE C-42 ❑C-36 OTHER NUMBE0. EXPIRATION DATE U l L LJ-/ l <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST #_ LDING PERMIT# LAND USE APPLICATION# <br /> BUI _—� <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: WftsmvicE ❑ COMMERCIALAA ❑ OTHER. <br /> NUMBER OF LIVING UNITS: NUM BER OF BEDROOMS: -4- NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC'TANK TYPEiMFG , CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG_ CAPACITY 901 #OF COMPARTMENTS_ <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL Ft FOUNDATION_ __. ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYsIF.M) <br /> f LEACH LINES ) LEACHING CHAMBERS E #OF LINES^ LENGTH OF LINES D.tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION_ R PROPERTY LINE <br /> ❑ FILTER BED WIDTH ft LENGTH _ft DEPTH ft <br /> DISTANCETONEAREST WELL H FOUNDATION_ ft PROPERTY LINE tl <br /> ❑ MOUNDED WIDTIi _ ft LENGni ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ SUMPS WIOTx __ft LF.NGTII ft DEPTH ft <br /> DISTANCETONEAREST WELL fl FOL'NDAT:0N ft PROPERTY LINE -^ft <br /> O DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL _11 FOUNDATION ft PROPERTY LINE R <br /> SEEPAGE PITS NvmorRWtmx _ft DEPTH fl <br /> DISTANCETONEAREST WELL ft FOUNDATION - ft PROPERTY LINE R <br /> T 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 COU M1-TV. <br /> MI IMl rflO w E <br /> NOTICE REQUIRED FOR ISSBEa'P =PL ASE CALL(209))33-7691 <br /> SIGNE TITLE DATE <br /> t <br /> 1171 1 <br /> `mayI T : <br /> W <br /> a <br /> I <br /> FTFT <br /> Z0 <br /> ifAYILIf <br /> I Ci <br /> i <br /> DEPARTMENT USE 9NLY / <br /> Application Accepted Date Arca `�„ -_ 8mplayec]D# <br /> Final Inspection By Date 7 ❑ SPECIAL PERMIT-Approved by_ <br /> Character or Soil to Dep of 3 Ft: __ _ PiUSump Soil Character: <br /> COMMENTS O_- ' � <br /> i PF. SC Received Amount ermitl - <br /> ode INPo Gate Remitted Date cSeroceRe uert# - nvoice>! PermitlDM <br /> � r t�o3B loU <br /> a1-02-001 ONSITE WASTEWATER PERMIT <br /> 128212003 <br />