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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 />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTION'S EXPIRES I YEAR FROM DATE ISSUED <br />JOB ADDRESS 3J �nj- CST (Zt I N CITY/ZIP l r/JJ (%�y <br />LA <br />H <br />i7j-s <br />CROSS STREETLP�IJt�1 11�IJ./rL( 11t/`� AP1q ��-l/ ' (% PARCEL SIZE �- 0 <br />0 <br />OWNF.RNAME r •t '�+/ �Jy/L�[,� PHONE <br />OWNER ADDRESS CITY/STATE/ZIP L419; <br />CONTRACTOR PHONE i <br />CONTRACTOR ADDRESS (Xx^j CITYISTATE/ZIP <br />LICENSE t&C42 ❑ C-36 OTHER NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: Il GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # _ BUILDING PERMIT # LAND USE APPLICATION # <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/MFG_Gi'/e--� CAPACITY '16GO gal #OFCOMPARTMENTS 7 - <br />GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />GREASE <br />❑ PKC TX PLANT DISTANCETO NEAREST: WELL /� tt FOUNDATION QST ft PROPERTY LINF. CO ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />ig LEACH LINES ❑ LEACHING CHAMBERS # OF LINES _� LENGTH OF LINES h <br />DISTANCE TO NEAR WELL J/)S ft F'OUNDA'TION JL' ft PROPERTY LINE QS ft <br />❑ FILTER BED WIDTH _ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL, ft FOUNDATION ft PROPERTY LME ft <br />❑ MOUNDED WIDTH ft LENGTHft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS WIDTH_ _ ft LENGTH It DEPTH ft <br />DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL fl FOUNDATION R PROPERTY LINE ft <br />i <br />PIX SEEPAGE PITS NUMBER � WIDTH � �r ft DEPTH 'JS- It <br />DISTANCE TO NEAREST WELL, /U3 ' ft FOUNDATION J/ ft PROPERTY LINE S%i fl <br />I HEREBY CERTIFY THAT1 HAVE PREPARED THIS APPLICATION AND THF, WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br />ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MLSIMUM 24 HOUR ADVANCE: NOTICE REQUIRED FOR INSPECTIONS -//PLEASE CAUL (209) 953.7697 <br />SIGNED TITLE/ �%ir,.L... DATE <br />�o <br />y <br />IM <br />Y <br />14 L G <br />-3c <br />rmN <br />_�— Date Area Employee <br />Application.— <br />Final Inspection v __�✓ Date 7 %/0�5�� ❑ SK IAL PERM IT -Ap roved by <br />Character of Soil to Depth ol13 Ft: it/Sump Soil Character: lyc..�GzG�_ t`�zz�aza <br />COMMENTS <br />© �� Tp�aa..r.YSi�— iinlc rs7+ '.�►t iby��=�✓✓✓ /.-i�c��'!—'�� )J _ .�l cY.-7 �-ir-� <br />PE SC Received Check#/ Amount Permit/ <br />Date Inv ice # Permit I fkt <br />Code INFO By s Remitted Service R uest # <br />tel( <br />02�� <br />4'02-001 ONSITE WASTEWATER PERMIT <br />12 22R00J <br />