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/'x^ <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT 304 E WEBER AVE-3'FL-STOCKTON CA 9S202-(209)463-3420 <br /> • NON-REFUNDA P T+(/ CALL(209} 53-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYIZIP! L�+�ILr� <br /> CROSS STREET 6r <br /> 00 AP r PARCEL SIZE 2 <br /> f��(I I <br /> OWNER NAME 4' PHONEsrz< ' p`T <br /> OWNER ADDACSS CITYlSFATE/ZIP 1 v <br /> 1 <br /> -7 7 <br /> CONTRACTOR _ /}1�t� ( _1 <br /> CONTRACTORADDRCSSA J \tJ�Kll.Jai /CIIITY/STAT`EEMIP <br /> LICENSE I(C-42 0C-36 OTHER• _ NUMBER ��I j� 5 FXPMATIOND4 1�✓ rO('� <br /> WATER TABLE DEPTH: R GEOGRAPHICALINFORMATION: Coordinates X YY 111 <br /> ❑ PERC TEST(S)_—M)MBF.R _ LAND USE APPLICAt70N# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION ❑ ENGINEER DWGNED/ALTERNATIVE L <br /> ❑ REPLACEMENT ❑ DESTRL'CrION L•Tl� <br /> INSTALLATION)"LL SERVE: RESIDENCE. ❑ COMMERCIAL ❑ OTHER_ <br /> NUMBEROF LIVING UNITS: NUMBER OF BEDROOM$: A NUMBER OF EMPLOYEES: <br /> Q <br /> ❑ SEPTICTANK TYPE/MFG _ CAPACITY gut #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPFIMFG CAPACITY gal #OFCOMPARTMENTS ,- <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL _ ft FOUNDATION tl PROPERTY LANE._........_ R <br /> ❑ LIFT STATION SIZE TYPE OP PUMP O SAND OIL SEPARATOR(ENCLOSED SYSMM) C <br /> LEACH LINES )If LEACHINGCHAMBER _ OF LINES LENGTH OF'LINES <br /> ___R �T <br /> DISTANCE TO NEAREST WELL 5O"1' R FOUNDATION 1 i R PROPERTY LME5.+-__.ft <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL_ R FOUNDATIONR PROPERTY LINE R <br /> ❑ MOUNDED WITH R LENGTH_ _ _ft DEPTH it S <br /> DISTANCE TO NEAREST WELL__A FOUNDATION,__„__„__ R PROPERTY LINE R <br /> ❑ SUMPS WITH R LENGTH R DEPTH R <br /> DISTANCE YO NEAREST WELL ___ft FOUNDATION „ft PROPERTY LINE, It <br /> ❑ DISPOSALPONDS WimH._ A LENGTH_ ft DEPTH R <br /> DISTANCE TO E51" WELL ft FOUNDATION ft PROPERTY LINE <br /> SEEPAGE PITS wtmTi �tt R LE� R DEPTH % ft <br /> D[.STANCE TO NEARESS WELL FOV NJA'f10 � R PROPERTY UNE R <br /> • 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORN WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> H U��11g1jjj,,,,A�QQQQQ\IVAJ�\CE NOTICE REQUIRED FOR I' 1 '.VS—P ASE CALL(201)453-7197 <br /> SIGNEDINTITLE >� DATE <br /> I <br /> VL <br /> 2 ENT <br /> O <br /> P <br /> DEPARTMENT USE ONLY / <br /> Application Accepted _ Date S-2-3 -©3 Arca�1 Employee ID# �9 <br /> Final Inspection Date .S fZ�"�63 ❑ SPECIAL PERMIT-Approved by_ <br /> Character of Soll ro pth of 3 Ft: Pit/Su mp Soil Character: <br /> COMMENTS <br /> PE SC Raeivtd CAmoUDt Dale Perm Invoice# Permit ID# <br /> Code INFO 8 ash Remitted le Service Rt uest# <br /> 421 li yIyo AS90033q <br /> • 42-01-007 t JO ONSITE WASTEWATER PERMIT <br /> 2 p2 <br /> s <br />