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I r <br /> r3 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3'°FL-STOCKTON CA 9$202 -(209)468-3420 <br /> NON-REFUNDABLE PER IT /4t' f^'' CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE <br /> DAgT.E ISSUED <br /> JOBADDRESS T �` CITY/ZIP m t+- ,u CJ1 ce 1 sY <br /> CROSS STREET tL's J a-,w..a��, �� /\ y`C. APN Z 1 I b -I?� PARCELSIZE <br /> e <br /> OWNERNAME PHorve 1y <br /> / y <br /> OWNERADDRESS —I� � S*b5-er 11- �1/. CITY/STATE/ZIP M/CL--r-C1A I-IJ <br /> CONTRACTOR "�-L PHONE <br /> a <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP _ <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE _-71 <br /> WATER TABLE DEPTH: -0-0 ft GEOGRAPHICALINFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I BUILDING PERMIT# - LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTA LLATIONWILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBEROFLIVING UNITS: (f NUMBER OF BEDROOMS: /[�� NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG 1' ` C'y� J G fY_ CAP AC Y Vim" gal #OF COMPARTMENTS _ <br /> ❑ GREASE TRAP TYPE MFG CAPA ITY gal #OF COMPARTMENTS <br /> r ��! <br /> ElPKG TX PLANT DISTANCE TO NEAREST: WELL (�O + R FOUNDATION "5 ft PROPERTY LIN ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R <br /> _/ DISTANCE TO NEAREST /WE R FOO�UND�FII,N R PROPERTY LINE R <br /> Cr KILTER BED WIDTH J ft LENGTH 7Ir ff0 S ft DEPTH 4, ' I <br /> DISTANCE TO NEAREST WELL L U V wT- R FOUNDATION C R PROPERTY LINET ft <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH R `I <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH R .9 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> G <br /> I 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 /> M IV/IIMUUMM 24 HOOU/jt ADV <br /> CE NOTICE REQUVRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ://.-�✓ /' !'�y/KI'� TITLE ( y. DATE <br /> C R <br /> c� J N <br /> 3p1,QJlN N <br /> r <br /> s o x <br /> . r <br /> I' 3 <br /> — <br /> I <br /> ._ AR 11jENT USF.ONL <br /> Application Accepted By ate Area Employee ID# V <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De th of 3 Ft: 'PiVWnp Soil C iter: <br /> COMMENTS <br /> PE SC eceived XhecidH- Amount Pe U <br /> Date InvDlce# Permit ID# <br /> Code INFO B -Cash' Remitted n Service Request# <br /> 4 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 12/22/2003 <br />