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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697FORINSPECTIONS J EXPIRE 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _ Al N / -CITY/ZIP <br /> CIO <br /> ' <br /> CROSS STREET (vD APN �U( I V 0 J PARCEL SIZE <br /> OWNER NAME PHONE 608 I � <br /> OWNER ADDRESS S A•. A_1eOPQ CITY/STATE/ZIP <br /> CONTRACTOR 'r,C/AU-0 ',,le ��6/Af%� � r/ PHONE <br /> CONTRACTOR ADDRESS /C✓ �iZ / l` • L�4/Y �+� CITY/STATE/ZIP � <br /> Ar <br /> LICENSE lirl IC-42 I -!C-36 OTHER NUMBER &2�777711 EXPIRATION DATE_ <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> U PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: i NEW INSTALLATION U REPAIR/ADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT F OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: -f2— ly NUMBER OF EMPLOYEES: �J <br /> �/ SEPTIC TANK TYPE/MFG CAPACITY �/iti O� gal #OF COMPARTMENTS 4— <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL �(/ l it FOUNDATION Vii` it PROPERTY LINE ' D ''P- ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> �__..._..__............ <br /> —_. — -- --- -------- — <br /> LEACH LINES ❑ LEACHING CHAMBERS #of LINES LENGTH OF LINES <br /> �Si 4 j it <br /> � � J <br /> DISTANCE TO NEAREST WELL it FOUNDATION� it PROPERTY LINE �� it <br /> ❑ FILTER BED WIDTH it LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it <br /> ❑ MOUNDED WIDTH it LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it <br /> ❑ SUMPS WIDTH _ it LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it <br /> ❑ DISPOSAL PONDS WIDTH it LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL f FOUNDATION it PROPERTYLINELINE it <br /> SEEPAGE PITS NUMBER S_ WIDTH :9 —it DEPTH :y it <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MININWO 24 HOUR 49VANCE NOTICE REQUIRED FOR INSPPE�CTION/S�-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE Ct (✓ DATE <br /> T <br /> N <br /> VI C U 1yo <br /> ge- <br /> E <br /> DEPARTMENT USE ONLY <br /> Application Accepte ✓ Date f 1 S f S Area C 9 Employee ID# <br /> Final Inspection B Date W �i EI SPECIAL PERMIT-Approved by <br /> Character of Soil to D pth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS Old 6if 6 ,,lo <br /> _Sc /G !l✓q�(L Gds LT_/Leh -�- - <br /> PE Sc ReceivedCheck Amount Permit/Code INFO B sh Remitted Date Service Request# Invoice# Permit ID# <br /> 0 / <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />