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M; Z <br /> a/ ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.H AZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERM C LL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _ CITY/ZIP4 _ <br /> -- <br /> CROSS STREE A PN_© v 5_ t60- 13_ PARCEL SIZE • f�O p <br /> (� v <br /> _-O _ ---- PHONE_ V m <br /> OWNER NAMEWE3 <br /> GrYbRAIDA <br /> OWNER ADDR }} _____CITY/STATE/ZIP V% __ <br /> CONTRACTOR 4 14� C PHONE <br /> CONTRACTOR ADDRESS46M W. Yv CITY/STATE/ZIP 1 S <br /> LICENSE Y C-42 C-36 OTHER_ /_ NUMBER1005 EXPIRATION DATE_____ <br /> WATER TABLE DEPTH:_ ft GEOGRAPHICAL INFORMATION: Coordinates X - _ _ Y_ <br /> Li PERC TEST # BUILDING PERMIT# _ LAND USE APPLICATION# <br /> TYPE OF ff <br /> N AL (b I M REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> � A W j <br /> � OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTIONETlL (xY✓� <br /> INSTALLATIon�$ haveOr <br /> $JpF�Jj 4 [� COMMERCIAL X OTHER Man i <br /> NUMBE <br /> MIME S: l� �_'(,I �f tJll MBER OF BEDROOMS:..__ NUMBER OF EMPLOYEES:. <br /> SEPT, CAPACITY CAPACITY gal #OF COMPARTMENTS_-___ _ <br /> ❑ GREAS6y4-pkrirofpM0pAao_a_ti''.__Myls-i n CAPACITY _ gel #OF COMPARTMENTSL�,.{. <br /> DISTANCE TO NEAREST: WELL 115(94__ ft FOUNDATION It PROI11-IifYLINE .J`�.-__- ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP - ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 10 LEACH LINES X LEACHING CHAMBERS _ #OF LINES_�— LENGTH OF LINES ft <br /> DISTANCE TO NEAHI_ST WELL. ft FOUNDATION—1 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 NE EST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SUMPS WIDTH ft LENG H _ DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> -- <br /> L3E1QG�`DISPOSAL PONDS WIDTH ft l7 ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE <br /> ❑ SEEPAGE PITS NUMBER WIDTH _ It DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. Fpq�Tgl'Y� <br /> M <br /> HO&R C R U/RED FOR if . IO - c rr CA(_!- 209 x,53-7697 FIV <br /> /Uu <br /> SIGNED _ TITLE -__ DATE <br /> 7 <br /> DEPARTMENT USE DNL Y <br /> Application Accepted By _ ___ -- Date_ Area � 1 <br /> _ Employee ID#_(�f <br /> Final Inspection By _ DateSPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft:_ l__ ' _ iPit/Sump Soil Character:�— <br /> gCOMMENTS (ot %A. _ !i l <br /> VW,L) � gj St�l <br /> k". w r^as(c �i• - dlnk n ( �l t V,: s' A- ' <br /> PE SC Received Zheck#f Amount D permit/ � <br /> Code INFO B71 _ Cash "ate Invoice# Permit ID# <br /> Remitted I <br /> _1, _Service Request# <br /> p <br /> 42-01 �i `f�li 'may //4 )•„F j S4tl/LT 6!% M �QC�MIT <br /> s 0 <br /> 4/24/12 <br />