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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE - 3- FL - STOCKTON CA 95202 • (209) 468-3420 <br />ryVIV-KEFUNUAIILE rLKmj 1 QC�,.nt�a.-% 71 7-1Jt rv�c a:-�ya7rn�� � w � GArIICL' J 1 Y EAR FROM LIATE ISSUED <br />JOB ADDRESS %� J. Y��• -{ L t� i �LOr1 a�CY� _ f'q CITYIZ1PyLf <br />CROSS STREET J�-'' �R" APN IiC ^ i^I 3- ^ 04 _ PARCEL SIZE S4 'k.9-1615 <br />OWNER NAMEM lZ - t'�L�I 4'�- 5 PHONE f /� <br />OWNERADDRESS r1,V�J� �a"�^,,,'`�((( [1'>� CITY/STATE/Lip_ OLY.1r'�.L CA, QSZOr - <br />CONTRACTOR �'-�a-'�^"L-�•'-`�} �.C-- PHONE <br />_�'}/{(plD� <br />CONTRACTOR ADDRESS O•, LO \„-ptJhllj t"'y'� - .r CITY/STATE/ZIP - \'R•yA1u <br />LICENSE O C-42 ❑ C-36 OTHER t��"1--� NUMBER &'e S09 EXPIRATION DATES - <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST (S) NUMBER LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDI ION ❑ ENGINEER DESIGNED/ALTERNATIVE. <br />O REPLACEMENT I)ESTRUCTIONS^IL '�A <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ <br />SEPTICTANK <br />TYPE/MFC _ , <br />CAPACITY gal #OFCOMPARTMENTS <br />❑ <br />CREASE TRAP <br />TYPE/MPG <br />CAPACITY _ . gal # OF COMPARTMENTS <br />❑ <br />PKC TX PLANT <br />DISTANCETO NEAREST: WELL <br />ft FOUNDATION It PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE fl <br />❑ FILI'ER RED <br />WIDTH R LENGTH <br />ft DEPTH <br />DVITAN'CETONEARESr WELL <br />ft FOUNDATION ft PROPERTY LINE fl <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCETONEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE fT <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH fl <br />DISTANCE TO NEAREST WELL <br />R FOUNDA1ION ft PROPERTY LINE_ -----__ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH A <br />DISTANCE TO NEARESr WELL. <br />ft FOUNDATION __ __ R PROPERTY LINE <br />❑ SEEPAGE PITS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL __ <br />ft FOUNDATION' ft PROPERTY LINE. it <br />1 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 RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM Z4 HOI1A ADVANCE NOTI E REQUIRED FOR INSPECTIONS -PI.E SF. CALL (209) 953-7697 <br />SIGNED TM. <br />�- <br />TITLE. 0 h -%A-1 kA—DATE <br />T(n. <br />i <br />I DEPARTMENT USE ONLY 2 <br />ApplicationAece�If'— <br />, <br />�--.,,__ Date ? Area 2�=1 Employee ID# Ool S /91 <br />Final lospectio , 1�Y Date�'/!� ❑ SPECIAL PERMIT -Approved byCharacterofSol Pit/Sump Soil Character.COMMENTl,ck -f,•. <F� r..oLt t.a�t ee! rnt .dam �.ti. hSr cam`. i. y+ <br />Date Invoice# Permit IDN <br />PC" SC Received Chee Amount Permit/ <br />Code INFO B aah Remitted Service Request # <br />O75 1�% L{f'%S 87•EJ P%f1149.00 39irjq°5 <br />A <br />42-01=001 <br />1212M2 vrvaiIc wna1cwniisR rtmviij <br />1 <br />