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l(YJT) <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> :IAN JOAQUI.N COLNTY ENVIRONMFNTAI.HEALTH DEPARTMENT 304 E WEBER.AVE-3M'FL-STOCKTON CA 95202 -(209)46tt-3628 � <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS )EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / / GQ/ ® CITYIZIP ��'A�� ✓ � Ll it/� _ m <br /> CROSSSTRELr2 6 APN noe, Q PARCEL SIZE. <br /> "7 /f �1 L. C <br /> OWNER NAaIF. y/// / /J�l�r�/I/I�[i,� PHO�NNE,�f31 f e yl)r�� <br /> OWNERADDRESS q5L ��}yEl in'n jj CITYISTATEIZIP �Lft <br /> CONTRACTOR _A/ /�i•flJ��' �X ,PHONE j-?�31 <br /> CONTiRACTORADDRESS J J -7/Ad" C17Y/SfATTILIP <br /> LICENSE -&-42 ❑C-36 OTHER --Z� Nt:MBFR EXPIRATION DATE_ <br /> WATER TABLE DEvt'H: Fl GEOGRAPHICAL INFORMATION: Coordinates X Y_ <br /> ❑ PERC TEST(S) NUMDER I.A1;D USF.APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION ❑ ENGINEER DESIGNED(ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> I!%'ST.ALLATiON WILL SERVE: ❑ RESIDFNCE ❑ COMMERCIAL ❑ OTHF.R <br /> NI;MHER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: y <br /> ❑ SEPTIC TANK TYPE%MFG_ CAPACITY gal 4 OFCOMPAKT.MENTS u�1 <br /> ❑ GREASETRAP TYPEIMFG CAPACITY go] #OF COMPARTMENTS `\ <br /> ❑ PKG TX PLANT DISTANCETONEARE$1': WELL ft FOUNDATION fl. PROPEKTY LINE tt C <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES�_ LENGTH Or LINES <br /> DISTANCE TO NEAREST WELL�ClS�� ft FOUNDATION -7 _fl PROPERTY LINE III <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH_ _ fl <br /> DISTANCE TO NEAREST WELL _ ft FOUNDATION _FI PROPERTY LNNE _ [l <br /> ❑ MOUNDED WIDTH ___ft LF.NrTH fl DEPTH ft <br /> DLS'TANCE TO NEARES'[ WELL ft FOUNDATION_ _ R PROPERTY LINE ft <br /> r J <br /> ❑ SUMPS WIDTH _- _ _—�fl LENcrx fl DEPTH R <br /> �� <br /> DlswkCETONEARFST WELL�b, „ft FOUNDATION �O l R PROPERTY LNNE <br /> ❑ DISPOSAL PONDS WIDTH fl LENGTH _ R DEPTH_ _ ft <br /> DISTANCE TO NEAREST WELL _ ft FOt:NDATIJN ft PROPERTY UNC ft <br /> ❑ SEEPAGE PITS WIDTH A LENGTH fl DEPTII ft <br /> DISTANCE TO NEAREST WELL ft FOUNJATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> .%TATE LAWS AND RILES AND REGUL.ATiCINS OF SAN JOAQUIN COUNTY, <br /> MINIMUM HOUR DVANCE NOTICE REQUIRED FOR:NSPECTIIONS-PLEASE CALL(209)953-7697 <br /> SIGNEDTITLF._SL/ DATE <br /> I <br /> All Tf <br /> PA <br /> 1 <br /> i <br /> E DEPARTMENT USE ONLY <br /> Application Accepted By ,q. <br /> Date_ I.,Q .Area Employee <br /> Final Inspection BY_ _ Date &n—Zj<Gq_ ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil tt:DeWfi of 3 Ft: Pit/Sump Sail Character: <br /> COMMENTS <br /> PE SC Received Amount Permit/ <br /> Invoice# PermitlD# <br /> Code INR) B Caah Remitted Service Request# <br /> E10 16 "° !t S Qo3lao <br /> a3-01-001 <br /> 121VO2 ONSITE WASTEWATER PERMIT <br />