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1 pfn <br /> q ONSITE WASTEWATER TREATMENT SYSTEM PERMIT t <br /> SAN'JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3-FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(2R9)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS v J CITY/ZIP 9 y <br /> /J � �1Y <br /> CROSS STREET _ APN 7—015-O(1 p// (J J PARCEL SIZE���_ a <br /> OWNER NAME �Ty�l"� /'�'L'.t!rI PHONE <br /> OWNER ADDRESS S CITY/STATE/LIP <br /> CONTRACTOR , C •Z .-SePHONE. <br /> CONTRACTOR ADDRESS 1C.✓ CITY/STATEILIP �r- <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER _ EXPIRATION DATE I c!WATER TABLE TABLE DEPTH: _R GEOGRAPHICALINFORMATION: Coordinates X y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> V REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: a RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS:_ J NUMBER OF BEDROOMS: NUMBEROFEMPLOVEES: <br /> 0 SEPTIC TANK TYPFJMFG _CTC (� ✓!��'_�_ CAPACITY �Zdp gaI #OFCOMPARTMENTS Z <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY_ _ gal #OFCOMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL IC->i.9• R FOUNDATION ?n fl PROPERTY LME <br /> ❑ LIFT STATION SIZE_ TYPE OF PUMP ❑ SAND 011.SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES it 1 <br /> DISTANCE TO NEAREST WELL R /FODUNDATION n PROPERTY LINE ft <br /> FILTER BED WIDTH J A_R LENGTH y O R DEP I-H R <br /> /- <br /> DISTANCE TO NEAREST WELL /,> <br /> fl FOUNDATION 3� R PROPERTY LINE �y _R <br /> C3 .MOUNDED WIDTH fl LENGTH R DEPTH R <br /> DISTANCE TO(NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ SUMPS WIDTH n LENGTH R DEPTH fl <br /> DISTANCETO NEAREST WELL R FOUNDATION ft PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH fl LENGTH R DEPTH ft <br /> DISTANCE To NEAREST WELL R FOUNDATION ft PROPERTY LINE fl <br /> ❑ SEEPAGE PITS NUMBER WDmI__ R DEPTH R <br /> DISTANCE To NEAREST WELL _ _R FOUNDATION it PROPERTY LINE. it <br /> I HERERY CERTIFY THAT I HAVE PREPARED THIS.APPLICATION AND THE WORK W ILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> � ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUN'TY'. <br /> M 11VIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEAS/E.CALL(209)953-7697 <br /> SIGNED TITLE ���' y DATE {Z <br /> I 7-7-77T <br /> loll <br /> R N <br /> H <br /> 1 <br /> 2 <br /> ,v <br /> DEPARTMENT LIPE ON1. <br /> Application Accepted A� to Area ;_;;> Employee ID# l l 1 l <br /> Final Inspection B _ Date L � ❑ SPECIAL PERMIT-Approved by <br /> Character or Soilto Dep D(3 Ft- Pit/Sump Soil Character. <br /> COMMENTS y ZQ <br /> PESC Received h Amount Date PermiU Invoke# Permit ID# <br /> Code Ipso 8 Cash Remitted Service Request# <br /> , o t 1 uo <br /> 42-0'JL2 -001 1 p, ¢r so h / fg g7� <br /> ONSITE WASTEWATER PERMIT <br /> 00k !^ <br />