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�/3a <br /> , <br /> ONSITE WA. 'EWATER TREATMENT SYS 'M <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEA LTH1DEPARTMENT 304 E WEBER AVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT LL 209 953-7697 FOR INSPECTIONS —EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS 0 eCITY/ZIP 6 al Z LA <br /> CROSSSTREET UA51,AI�zk ad- APNOFC—6 0- 71/ PARCEL SIZE !Z•3�l a� a <br /> d <br /> i �� 1 PHONE 116-960- 1�/�JO <br /> OWNER NAME _ ITV ti O ,,. <br /> ��,CCC41'Z3() �r r, <br /> OWNER ADDRESS rf ,) �I V CITY/STATEIZIP PG 1.4.A r c I,Ah.l,64 L L7�6 <br /> CONTRACTOR 1`�I� V r h T� ` <br /> HONE <br /> CONTRACTOR ADDRESS t CITYISTATEIZIP 1-D <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> Z PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ~ <br /> ❑ CREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PK(;TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft A <br /> ❑ LIFT STATION SIZE TvPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> f DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> © SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 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 OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQLIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED /' J r' TITLE DATE L16 77 <br /> Mill <br /> G1letL f <br /> 1 <br /> k V <br /> IV MI{ <br /> RAIN Ull Lull)U M <br /> k <br /> N IFI N E <br /> EP w VENT <br /> EP RT ENT US ONL <br /> Application Accepted Date Area Employee ID# !y� <br /> Final Inspection B Da e / ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De of 3 Ft; it/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Che Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> b oa 5o 2 <br /> T T- <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 121221244] <br />