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r, D ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> $AN AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE-3"°FL-STOCKTON CA 95262 -(209)461-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR I NSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> -Ioqi2i11wl � <br /> JOBADDRESS 11 �+ CI^ry,2f1�P1L N /A <br /> �Q <br /> CROSS STREET �I LI�� S /N /� APN LlJl�E) PARCELS[.' _ <br /> OWNER NAME STIY1^ I R,/�AA.$.I�'��T tyC PHONE�i <br /> OWNER ADDRE \SS /'lYV1 CM/STATVZIP hW <br /> CONTRACTOR '1 Se-01jiI PIION <br /> CONrRALTOR AD0PE5N CRYISFATTIZIP <br /> LICENSE 13 C42 -36 OTHER NUMBER EXPIRATION DATE _ <br /> WATERTABLEDEPM: R GEOORAPHICALINFORMATION: Ccordl--1 X V <br /> ❑ PERC TEST N BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION KEPAIR/ADDRION CI ENGINEER DESIGNED/ALTERNATIVE <br /> O RvwceMENr ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER <br /> NUMB EROPLIVINGUNIIE: NUMBER OP BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY Eel MOFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFO CAPACITY Ed NOFCOMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCETONEARESe: WELLB FOUNDATION B PROPERTY LINE R <br /> ❑ LIFT STATION SITE TYFEOFPUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS NOFLINE$ LENGTHOFLINE.S fl <br /> DISTANCETONEAREST WELL fl FOUNDATION fl PROPERTY LINE D <br /> �T] FILTER BED WIDTH L.4 I fl LENGTH SIlI re ft DEPTH fi�I it rn <br /> 1 - DISTANCE TO NEAREST' WELL �Z�e'1 fl FOUNDATION SCJ fl PROPERTY LINE fl <br /> ❑ MOUNDED WIoTx n LENGTH fl DEPTH It _ <br /> DISTANCETONEAREST WELL D FOUNDATION R PROPERTY LINE fl <br /> ❑ SUMPS WIDTx R LENGTH fl DEPTH fl <br /> DIBTANCETONEARETT WELL R FOUNDATION D PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WWI, fl LENGTH B DEPTH fl <br /> DISTANCE TO NEAREST WELL It FOUNDATION B PROPERTYLME fl <br /> ❑ SEEPAGE PITS NUMBER WIoTx fl DEPTH D <br /> DISTANCE TO NGREST WELL R FOUNDATION D PROPERTY LINE fl <br /> 1 <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN WITH BAN JOAQUIN COUNTY <br /> JOAQUIN COUNTYW <br /> NINI UM J4 NO UR ADVANCE NOTICE REQUI RED FOR I NSPECTI IINS-PLEASE CALL 12091953-7697 �-1 <br /> SIGNED � TITLE !llAlpl _ DATE _� / <br /> N <br /> 5 I L <br /> O <br /> P <br /> V <br /> 7 Q <br /> IA <br /> :l <br /> PARTMEN.T O Y <br /> Appikellon Accepted B Dale l Area EmFWYee IDM V s <br /> FIRM Inspection By _ O ❑ SPECIAL PERMIT-Approved by <br /> Chmcw of Soil to Depth of3 Ft: Pit/Su Soil Character. <br /> COMMENTS <br /> PE <br /> SIC Received A�Nruxt Onto P<rmlU Invoice Perndt IDN <br /> Code Info B a Remitted SerNccR ueNM <br /> b0 N <br />