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ONSITE WAST ATER TREATMENT SYSTT-'`T PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP_-RTMENT 304 E WEBER AV.k,-f3"'FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS C1 1 Cf r CITY/ZIP L tBrC j2 S 7 a <br /> CROSS STREET 15 L-rend APN t� ( � t PA SIZE O�Cl -72 <br /> nov <br /> � <br /> OWNER NAME V iA T, LZ I? L?`-�/�i+ 1�'7 C, v-f AGI U� _W_il)Qt✓fN PHONE Y� <br /> J ji <br /> OWNER ADDRESS / J7i�(/ � �I �T1 ___- CiTY1STATE/ZIP �G� <br /> CONTRACTOR �/fAr,?II Ir4 SI` � .f.'.,_. ., T PHONE <br /> CONTRACTOR ADDRESS N? iu. &141�i'!`�afn _. (���� CITYISTATEIZIP_ �QL_�_ fF <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER 63/-741 EXPIRATION DATE__L1 3c� ZGc i <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y _L <br /> ❑ PERC TEST(S) NUMBER 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 /> SLD SEPTIC TANK TYPEIMFG In CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES 13 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH t3 LENGTH ft DEPTH tt Ey <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH tt <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 /> 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 /> M 2 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNE TITLE L' DATE 4 d 3 <br /> '•�,- I..� ' lam✓ YID 1 I <br /> ;. P�°Q•I.,. _ ��_ =fi=g --_, l,:� .•I I P. �, SG.'V�G � <br /> ' II <br /> .fin <br />'-��W _MF' •� ►' Jn4 ry T 'Y TyW� r:+.�t r+re" "^-�f^"' �I`V's ` -�,_\_.A/ -.�,�'_•q yr.• .. <br /> re- <br /> -- -u YA*FNiE�7f1) E ONLY'_I_ u <br /> t/qR <br /> Application Accepte y Date Area �-+ Employee ID# <br /> Final Inspection Date �,�/( ❑ SPECIAL PERMIT-Approved by <br /> Character of Sa th 3 Ft: - Pit/Sp p Soil char <br /> COMMENTS JA <br /> PE SC Received Check#1 Amount Date Permit) Invoice# PermitID# <br /> Code LNFO B as Remitted Service Request <br /> # <br /> �Z � _-S-R-00) S` <br /> 42-01-001 <br /> ONSITE WASTEWATER PERMIT <br /> 12!2!02 <br />