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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HF.AUTH DEPARTMENT 304 F.WEBER AVE-3"FL-STOCKTON CA 95202 • (209)463.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS Crrv/ZIP 4- J _(7 (?C 2!j 2 <br /> CROSS STREET ' `_ APN S �T PARCEL SIZE <br /> OWNER NAME l-d Yy� �I mein Q�7 C`r�1O.(IL� � PHONE 28-T <br /> OWNERADDR M W Its SP I r14 a CITY/STATE/ZIP LbA' C, !25--2- <br /> - 1 �_ <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CTTYJSTATE/ZJP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH:_ R GEOGRAPHICAL INFORMATION: Coordinate% X 'f <br /> ❑ PERC TEST # p�� BUILDING PERMIT# LAND USE APPLICATION fl <br /> TYPE OF WORK: )W_ NEW INSTALLATION O REPAIRIADDITION O ENGINEERDESICNEDIALTERNATME <br /> REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: II-RESIDENCE ❑ COMMERCIAL ❑ OTHER_ <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPEIMFG ScAJEE� CAPACITY 12!00 gal #OF COMPARTMENTS Z- <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETO NEAREST: WELL ft FOUNDATION It PROPERTY LME ft <br /> O LIFT STATION SIZE TYPE OF PUMP O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBF.RS #OFLINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LME ft <br /> FILTER BED WIDTH 20 ft LENGTH LFG ft DEPTH 3 /Z-- ft D <br /> DISTANCE TO NEAREST WELL it FOUNDATION_ R PROPERTY LME It ^� <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH it �Q <br /> DISTANCE TO Nr.ARF-qr WELL ft FOUNDATION_ R PROPERTY LINE It <br /> ❑ SUMPS WIDTH_ ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL 0 FOUNDATION r R PROPERTY LINE R <br /> ❑ DISPOSAL PONTIS WIDTH ft LENGTH_ ft DEPTH R <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION ft PROPERTY LINE R � <br /> ❑ SEEPAGE PITS NUMBER WMTH R DEPTH ft (+ <br /> DISTANCE TO NEAREST' WELL R FOUNDATION ft PROPERTY LINE R Q <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY A <br /> ORDINANCES,STATE LAWS AND RULES A14D REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MI� OUR A INCE NOTICE REQUINO FOR IMM"IONS-PLEASE CALL(209)953-7697 <br /> SIGNED ��� �77�`LL TITLE �uJ rY%e DAT <br /> �l PAYMENT Nge <br /> q RECEIVED <br /> ;\ FEB 2 2005 <br /> 40 n <br /> `Fc SAN JOAQUIN COUNTY <br /> vI,t1R / H NTN DEpARITMENT <br /> Q� `• \ Ir J x a j / <br /> IL <br /> a <br /> Q Q 1 <br /> �TRrn. 1 <br /> DEPARTIIILNT ONLY <br /> Application Accepted By L►sY Date O S Area Employee HIM <br /> Find Inspection Sy jr,Date 13SPECIAL PER IT-Approved b� <br /> Character of Sail to Depth ! Pit/Sump Soil Character: 941T %c+ <br /> COMMENTS D L.A "-T 0 <br /> PE SC Received ecioWAmount Permit/ <br /> Crede INFO B Remitted Date �. a Invoke, Per I <br /> o� ~ <br /> A+-2.r0 ff5 SS d'O.Oc? <br /> i ^/J <br /> I n2/2 01 <br /> (�Q 'A9�lRBR ERIM�T <br /> 2R003 I '^^ <br />