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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY'ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3°0 FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 3 j 1(,oZ / a Cc-s(�. L 7 CiTYfLIP I PII.+Ac Ts 3o ` a <br /> CROSS STREET Lo.,. FcSI r� . 1 APN C9 g PARCEL SIZE • �' o <br /> OWNER NAME 4,- )- 11 lle.f PHONE ���1 '533-9517 <br /> 9 <br /> OWNER ADDRESS ;L31to 2 LA C ,&SG LT CITWSTATEIZIP TfRby I L4 A� S3G�0�—f <br /> CONTRACTOR SC I F PHONE o2 • i C�331' •�! ` <br /> CONTRACTOR ADDRCSS CITY/S`rATEIZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE —� <br /> WATER TABLE DEPTH: 7 fl GEOGRAPHICALINFORMATION: Coordinates X Y <br /> ElP£RC TEST N�_ BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEERDESIGNEDIALTEP-NATIVE <br /> REPLACEMENT 51'�}I C, TL./Y X.. ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: C&RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> — <br /> NUMBEROFLIYINGUNITS: NUMBER OF BEDROOMS: / NUMBEROFEMPLOYEFS: <br /> SEPTIC TANK -NPE/MFG-E+L CAPACITY�cnogal NOFCOMPARTMENTS '2 ,1 <br /> ❑ GREASE TRAP TYPEfMFG CAPACITY Pal N OFCOMPARTMENT,SS Iv <br /> ❑ PKG TX PLANT DISTANCETO NEARCST. WELL.__„3OD ft FOUNDATION— A PROPERTY LINE a R �/- <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLQsED SYSTEM) r <br /> ❑ LEACH LINES '❑ LEACHING CHAMBERS .� #OF Li%ES LENGTH OF LINES ft N <br /> DISTANCE TO NEAREST WBLL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ FILTER BED WIDTH_ R LENGTH _ft DEPTH ft (� <br /> DISTANCETO NEAREST WELL ft FOUNDATION i ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEARYST WELL ft FOUNDATION f[ PROPERTY LINE ft <br /> ❑ SUMPS wiDTH ft LrNGTH ft DEPTH ft <br /> D157ANCE TO NEAREST WELL__A FOUNDATION ft PROPERTY LINE <br /> ElR A /1 <br /> DISPOSALPONDS WIDTH LrNGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL A FOUNDATION A PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH _ ft DEPTH ft T <br /> DISTANCE TO NEAREST WELL ft FOUNDATION A PROPERTY LINE ft X <br /> 1 HEREBY CER THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> OR ANCES ATE LAWS AND RULES AND RECULATIONSOF SAN JOAQUIN COUNTY. <br /> IMU HO C 'CE REQUIRED FOR INSPECTIONS-rPI.FA.SF.CALL(209)953.7697 <br /> SIGNED TITLE 4jet4l Por �Aer DATE I I�o8ro� <br /> ll <br /> IF <br /> JL <br /> ZM <br /> I Ile. <br /> y <br /> t(- <br /> 1.- - <br /> 7� f_ <br /> 1 RM <br /> DEPARTMENT Ls 6OV Y <br /> ApplicatlOn AceepK'd BY �7 � e // V I { Area ❑--1 Employee IDN ,pA <br /> Final Inspection Hy 7i� Date��-� �'-// y ❑ SPECIAL PERMIT-Approvod by <br /> Character of Stoll to De of 3 Ft: Pit/S' ump Soil Character: <br /> COMME,xrs <br /> PE SC Re elved Tec Amouat Permit/ Ievoke# Permit IDN <br /> Code IAFo B ash Remitted at Service R ueat it <br /> o rl ' II K <br /> I jog <br /> 9 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 17222003 <br />