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NSITE WASTEWATER TREATMEDQ9,SYSTEM PERMIT <br /> -SAN JOAQUIN COU IRONMENTAL HEALTH DEPARTMENT WEBER AVE-3R'FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(109)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED m <br /> JOBADDRESS S- CITYIZIP / t~n <br /> PARCEL SIZE <br /> CROSS STREET APN <br /> 4 �J M <br /> OWNERNAME PHONE O -w <br /> {I - OWNERADDRFSS h CCITYISTATEIZIP S.—J L <br /> CONTRACTORk1.�J1• `(/c� PHONE o <br /> 2405 <br /> CONTRACTOR ADDRES Vf� ,FyF <br /> O N Y_ ,`,sOr CITYISTATEIZIF 1 <br /> LICENSE C42 ❑C-36 OTHER A NUMBER 05 ExPIAATION DATE �O O <br /> WATER TABLE DEPTH: fl GEOGRAPHICAL INFORMATION: Coordinake9 X Y <br /> JJJ ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: X NEW INSTALLATION ❑ REPAIRIADOtT1ON ❑ ENGINEER DESICNED IALTERNATIVE r,, <br /> Z! REPLACEMENT (3DESTRUCTION v <br /> INSTALLATION WILL SERVE: ARESIDENCE ❑ COMMERCIAL ❑ <br /> OTHER—UMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: /n L\ <br /> SEPTIC TANK TYPElMFG <br /> �+ G CAPACITY gal 4 OF COMPARTMENTS r V <br /> } � CAPACCTY gal ft OF COMPARTMENTS <br /> CI CREASE TRAP TVPElMFa 6 <br /> PKG TX PLANT DISTANCETO FAIREST: WELL 't fl FOUNDATION ft PROPERTY LINE 1 *tl <br /> ❑ LIFT STATION Siz (I TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> Iq LEACH LINES fTs. LEACHING CHAMBER 4U) #OFLINES _A LENGTH OF LINES—­J00fl <br /> ^^ DISTANCE TO NEAREST WELL �ft FOUNDATION0 ft PROPERTY LINE_ - ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH 11 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ` ❑ MOUNDED WIDTH fl LENGTH ft DEPTH ft <br /> RRR DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> C1 SUMPS WIDTH ft LENGTH ft DEPTH R <br /> 1 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WD)TH R LENGTH f1 DEPTH ft <br /> _ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft 'LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> 1f^/' ( INIMftmr <br /> ICE REQUIRED FOR PE IONS-PL ASE CALL(209)953-7697 0 <br /> SIGNED �JC`� ' TITL DATE <br /> F" <br /> qr <br /> jim <br /> - <br /> i <br /> S <br /> r <br /> R N E <br /> f,) -alf 4:1f - L-LI .1 1 -1 <br /> DEPARTMENTE NLY ��� <br /> r <br /> Application Accepted By C3 Area� Employee ID# �(/� <br /> Final Inspectlon By Date p ❑ SPECIAL PERMIT-Approved by I I <br /> Character of Soil to � th of 3 1;q PI Sump Soil Charac er: <br /> COMMENTS r, N��la�rr'��r AA�1,,� <br /> 0 v 1, <br /> PE SC Received heck#1 Amoun Per' <br /> mitt Invoice# Permit IDN <br /> Code INFO B as Remitted <br /> at Service R uesl# <br /> kZ 31 f 11 M1516 -3 9ju, <br /> 0�375� <br /> 42-01-001 Z 9G/ I/ ONSITE WASTEWATER PERMIT <br /> I zn1oz <br />