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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-3t°PL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE <br /> �PJERMITCALL 209 953-7697 FOR I'SPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> f JOBADDRE45 �J S \�C p\..� CRY21P �/. l <br /> LCROMSTREP ` I }' APN V� t PARSEL SIM <br /> 1 R <br /> OWNER NAME CSV C , l �_,� ( , PHONE t.7 40 a) t +� <br /> OWNER ADDRESS ,! _ .tom K_— CT'/STATEIZIP �I T <br /> CONTRACTOR PHONE <br /> CONTRACEOR AGGRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WW ITER TABLE DEPTH: ft GEOGRAPHICALINFORMATION: Coordinate R Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION III <br /> TYPE OF WORK: ❑ NEWINSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNEDIALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> L INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OV EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY sol #OFCOMPARTMENTS <br /> L ❑ GREASE TRAP TYPF/MFO CAPACITY Sol #OFCOMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETONEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> L <br /> LI LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OFLINES LENGTH OFLINES ft <br /> DISTANCE TO NEAREST WELL fl FOUNDATION 8 PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH a <br /> DIETANCETONEAREST WELL R FOUNDATION fl PROPERTY LINE H <br /> 11.,I ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETONEARESI WELL fl FOUNDATION fl PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH IF DEPTH R <br /> DISTANCETONEAREar WELL It FOUNDATION fl PROPERTY LINE ft <br /> to ❑ DISPOSAL PONDS WIDTH fl LENGTH ft DEPTH ft <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LME fl� <br /> ❑ SEEPAGE PITS NUMBER WIDTH A DEPTH ft <br /> LDISTANCETONEAREST WELL ft FOUNDATION B PROPERTY LINE fl <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OR SAN JOAQUIN COUNTY. <br /> 1 M INI MUM 24 HOUR ADVANCE NOTI CE REQUI RED FOR INSPECTIONS-PLEASE CAL.LyI?09�1913-7697 _ <br /> L SIGNED P TITLE i� v DATE 7 <br /> _1 <br /> ENVIRDNA <br /> L 1 <br /> L S <br /> E <br /> bq rpr)s TM EN <br /> 1 DEPARTMEr UK <br /> ...h'. /2E ONVY <br /> Applirotbn Accepted BY � �+".J � _- � `�—' Date / L) O � Arm Empl6yee ID# <br /> FIRM Inspection BY / � Bete ❑ SPECIAL PERMIT-Approved SY <br /> Illin, Charoctcr of Soll to Depth of 3 Ft PNSump SOR Ch.ncter: <br /> COMMENTS <br /> PE SC Receival C_hcel*_3 Amount P..tl <br /> Cole INeD B Ceh Remitted Date Sershe Reci.ect# Invoice# Parmit IM <br /> L7L-1 57 3KO i 44: -7 <br /> 4243401 ONSITE WASTEWATER PERMIT <br /> ' I]RTRINI3 ' <br />