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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQVIN COUNTY ENVIRONMENTAL HEALTH DFPARTMF.NT304E WEBER AVE.-3-FL-STOCKTGN CA 95202 - (209)469-34120 <br /> NON-REFUNDA E PERMIT r 1CALL 1� �((2200J9))9`53--7w69`7 rOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS _ �Rs r�"fGIV�1v,-.7.[/���t3N IV CITY/ZIP <br /> CROSS STREET _ � { om 1 2 -�1I l� PO <br /> APN PARCEL SIZE � <br /> OWNER NAME $2PItONE <br /> OWNER ADDRESC 7{�F)71-{ V+/ CITY/STATF./ZI <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITV/STATFJZI )52 <br /> LICENSE C42 ❑U-36 OTHER MEMBER EXPIRATIGY DATE <br /> WATER TABLE DEPTH: fl GEOGRAPIIICALINFORMATION: Coordinates X Y <br /> ❑ PERC TEST #' $VILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION RFPAIR/ADDrrION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESIRIICTION <br /> INSTALLATION WILL SERVE. 1 RESIDENCE ❑ COMMERC'IAL /'7^ LJOTHER_ <br /> NUMBER OF LIVING UNITS: 1 NUMBER OF 13FDROOMS: ✓ NLMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG_ _ CAPACTIY gal 0 OF COMPARTMENTS <br /> ❑ GREASE'TRAP 'TYPE/MFG CAPACITY grl #OF COMPARTMENTS <br /> ❑ PKC:TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION tl PROPERTY LINE ft <br /> ❑ LIFT STATION SIzE TYPE OF PLMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES A LEACHING CHAMBER�3 -J ) #OF LINFs LENGTH OF LINES tt <br /> DISTANCE TO NEARESTWCL 1 _ ft FOUNDATION ft PROPERTY LINE <br /> ❑ FILTER RED WIDTH tl LENGTH_ _ft DHPTH _ —ft _3 <br /> DISTANCE TO NEAREST WELL_ ft FOUNDATION ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH ft LEPIGIH ZAFH DEPTH <br /> DISTANCE TO NEARLY1 WE,1.1. Il FOUNDATKN�''�''''''TTT777���A PROPERTY LME R }{ <br /> SUMPS WIDTH-fin LENGTH DEPTH R <br /> DISTANCE TO NEAREST WELL I t ft FOUNDATION R PROPERTY LINE R <br /> 0 DISPOSAL PONDS WIDTHft LENGTH_ fl DEPTH —ft <br /> DISTANCE TO NEAREST WELL ,ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH R <br /> DISTANCE To NEAREST Lt. II FOUNDATION ft PROPERTY LINE ft 2IINN�� <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TF,E WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> H R DVANCF.NOTICE RF <br /> ,QUI RED FOR I ONS-P ASF.CALL(209)953-7697 <br /> SIGNF. TITL� DATE 05 <br /> i <br /> I <br /> A J 11V <br /> RT E T <br /> DT.PADate T 'Sys E 9!ILY' - �4 <br /> Application Accepted 6 <br /> ,� Date_S, l_l f C''� Area ,�Z Employee IDN <br /> Final Inspection By __ % Date� `:V ❑ SPECIAL f):RMIT-App 01 <br /> ed by <br /> Character of Sol[to Depth of FI: - •>2 PIUSum/Jp Soil Character-. n <br /> 7 <br /> .6 <br /> COMMENT'S � 4 0" <br /> S <br /> C,L S +c GO A--j A rC— zz c��Qorr� <br /> pE SC Received Check# Amount Perndl/ Involce# Per It ID <br /> Ctlde INco B as Remitted <br /> Date se-ice Re nest# <br /> D Ig-C) a�) I / 0 5 0D4O955 <br />