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V-W 1"1/1 <br /> L 7NSITE WASTEWATER TREA- TEP SYSTEMPERMIT <br /> SAN JOA�OU�VIRONMENTAL HEALTH DEPARTMENT �IEP- <br /> AVE-3Y°FL-STOCKTON CA 95202-(209)ffi&3120 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> L JOBADDRESS -lI20I1Ntiriner Ad <br /> o�1CnIv/+0ZO1IP��IEi YGIOh <br /> CROSSSTREEF APN ZZ- - rPA <br /> RCELSIZIy <br /> 6l > <br /> OWNER NAME Pull., °^P PHONE 0-0-1OIfq p <br /> G <br /> OWNER ADDRESS J YnI Qi CITY/STATE/ZIP — <br /> CONTRACTOR fowntl- PRONE <br /> CONTRACTORADDRESE CITY/STATFJZIP <br /> O <br /> LICENSE L3 C42 13 C-36 OTHER NUMBER E%PIRATION DATE <br /> LWATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: CBBrelealef X Y <br /> ❑ PERCTEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEWINSTALLATION ❑ REPARVADDRION ❑ ENGINEERDFSIGNEOIALTERNATIVE <br /> F ❑ REPWCEME ❑ DESTRUCTION V <br /> LINSTALLATION WILL SERVE: RERmENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBEROFIBLNEDD`R__OOMS: / ry� NUMBER OFEMPLOYEFS: <br /> SEPTICTANK TYPE/MFG �LMYr w (..Q#�CREYC.�CAPACTT ILL gel #OFCOMPARTMENTS 5 <br /> O GREASE TRAP TYPF/MFG CAPACITY gel #OFCOMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETONEARESI': WELL B FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPEOFPuIAP ❑ rSTAND OIL SEPARATOR(ENCL(OS/E�)SYVTEM) C <br /> LEACH LINES 13 LEACHING CHAMBERS #OF LINES °S LENGTH OF LINES CVLJ B �T <br /> DISTANCETONEAREST WELL�y�ft FOUNDATION 10 ft PROPERTY LINE it <br /> t <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH B p <br /> L DISFANCETONEAREW' WELL ft FOUNDATION 0 PROPERTY LINE it d <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATMN ft PROPERTYLINE B <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH ft <br /> iDISTANCETONEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> tow13DISPOSAL PONDS WIDTH It LENGTH It DEPTH ft <br /> DISEANCETONF(AREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS Wmix y"Z R LENGTH ft DEPTH ZS/ 'J It <br /> L DISTANCE TO NEAREST WELL 'LOO ft FOUNDATION ID A PROPERTY LINE 3 HID ft <br /> 1 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 /> MINud6M L HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL ON)957-7697 1- ? <br /> SIGNED / TITLE DATE J <br /> L <br /> 1 <br /> L 1 <br /> 1 <br /> I <br /> I <br /> *W SA 4 JGAGJIN CO N <br /> LIL MU LIN�cm'lu- <br /> Iri <br /> 60 <br /> DEPARTMENT USE ONLY-T <br /> ApplicatH.Accepted BY I Date r�11-QD A. a1�i EmplDye,10# y7T <br /> L Final 1, cBon By Date /l am ❑ SPECIAL PERMIT-AppmvN by <br /> Character of Soil to pth FO WSump Soil Character: <br /> COMMENTS <br /> L PER SC Received hec Amount Data Pernik/ Invoice# Permit lDp <br /> Code InEO B Remitted Service Request# <br /> L ¢211117 k 4, 1 320 033 <br /> 12-01-001 ONSITE WASTEWATER PERMIT <br /> 112(3 <br />