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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENYIRONMENTAL HEALTH DEPARTMENT 304 E W FRKR AvE-3-FL-STOCKTON CA 95702 -(209)168-3420 <br /> NON-REFUNDABLE PERMIT CALL 9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> v r �ssx rA <br /> doBADDaEss /� C1TYfZ[P P <br /> n <br /> CROSS STREET' 1/ar1 A-l" APN cZ i I[fe/� Q� PARCELS= (J ��� 9 <br /> 0 <br /> cc � v <br /> V15-2771"'OWNER NAME C ��� PHONE 15-2 7 7 / <br /> OWNERADDRESS IS/ �Jl,r-+qtr " CrrYlSTATEIZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY ATFJ P <br /> i <br /> LICENSE l7 C-42 ❑C-36 OTHER _ NUMBER EAPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinate$ X Y <br /> I` CI PERC TEST N BUILDING PERMIT#6e A LAND USE APPLICATION# <br /> I TYPE OF WORK: ❑ NEW INSTALLATION O REPAIR/ADDITION ❑ ENGINeestftSiGNED.IALTERNATIVE <br /> O REPLACEMENT ❑ DsslRucnuN <br /> INSTALLATION WILL SERVE: ;@ RESIDENCE ❑ COMMERCIAL CI OTHER <br /> NUMREROF LAVING UNITS: L400 NUMBER OF BEDROOMS: l� �l NUMBER OF EMPLOYEES: <br /> I <br /> SEPTIC TANK TrPE(MFGCAPACITY IG U U gal SOF COMPARTMENTS <br /> i CI CREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETONEAREST: WELL ft FOUNDATION ft PROPERTY LINE R <br /> 1 ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR <br /> (ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER HED Wlutx ft LENGTH ft DEPTH ft <br /> OWTANCRT'ONP.AREST -WELL fl FOUNDATION ft PROPERTY LIME ft <br /> ❑ MOUNDED WIDTH H LENGTH R DEPTH it <br /> DISTANCE To NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTii ft LENGTH ft DEPTH R <br /> DISTANCETONEARFST WELL ft FOUNDATION fl PROPERTY LINE R <br /> ❑ SEEPAGE PITS NuMBEB WIOTx R DEPTH R <br /> DISTANCETONRAREST WELL ft FOUNDATION ft PROPERTY LINE_ft <br /> r 1 HERESY CERTIFY THAT 1 HAVE PREPAREDTHIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br />!1 <br /> ORDINANCES.STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE.CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> 1 <br /> 11 tA <br /> } <br /> "1 <br /> A f - <br /> t? fk <br /> I I _ <br /> i <br /> 1 <br /> EPARTMEN USE LV Q� <br /> ry AppHcatbDAcr•epTeR - Dote" Aradmployee <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approvod by <br /> Character of Soil to of3Ft: PWSumpSoil Character: <br /> COMMENTS / w: -J—?N< <2` i7yt.2w w / <br /> e"4 .-��F/.s 7 •,l.0 ,�Ic eS:L, ria 4+45= 3Ac,eb <br /> G" Yep''/�GL. T� .S'., c.fi3- -fie. • ��C �L.�-`5�!' Se+�v��o�.aLsGcLl23 '..- � d4�7 <br /> PE SC eceived Ch Amount PermiU Invoice# PermII1D# <br /> Cade INFO B asDate h Rendeted Service R vent# <br /> 42-07-001 !''¢yl•,.57eZe Ze, 4-.,mLS-1zM1D- ,'s �v- 40 41,J) . <br /> / ONSITE WASTEWATER PERMIT <br /> 122212D03 <br />