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S <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT 1 p <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS <br />�l <br />JOB ADDRESS " 4�/�� Z ##-- I �� <br />CITY/ZIP <br />CROSS STREET DGf A-40. APN I O' <br />_ O;O ^ O'� <br />'`,WooIflB21 <br />OWNER NAME OA IN u /� ��D N 44-1 ^ <br />Q, <br />DISTANCE TO NEAREST WELL <br />,/Li <br />OWNER ADDRESS pt�fj 6 7 • �MG I FIL /?� ✓Fi ' y <br />CONTRACTOR �� `� •' /"•� ~�Z" % <br />CITY/STpATE/ZIP G <br />PHONE' <br />CONTRACTOR ADDRESS C) - f,3,) / y U <br />CITYISTATE/ZIP <br />LICENSE Call "C-36 OTHER NUMBER <br />EXPIRATION DA' <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />CI /9 5-2.142 <br />Zo,>4a <br />O . <br />PARCEL SIZE Y <br />0 <br />z <br />_ PHONE y <br />S%vI:I�TYrIC4 / QrLa7 <br />Z-oa1,/ca/9sLY- <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />ix PERC TEST # BUILDING PERMIT # LAND USE APPLICATION <br />PE OF WORK: <br />NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -0F -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: C RESIDENCE COMMERCIAL 1 OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br />❑ GREASE TRAP TYPEIMFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH <br />It <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY UNE <br />ft <br />A <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY UNE <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE <br />1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINAN <br />Y V <br />MINIMUM <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />4 HOUR ANCE NOTICE REQUIRED FOR INSPECT ONS - PLEASE CALL 209 953-7697 <br />-/ <br />i1q <br />'y�47V <br />1Q <br />O l✓M1 <br />q<,yry <br />SIGNED TITLE 7 DATE yoFp <br />RFT <br />MFNT <br />I <br />I • <br />I <br />PESC Re <br />Code <br />d Che Amount Dae Permit/ Invoice # Permit ID# <br />Code INFO ash Remitted Service Re uest # <br />y;a. S-23 / (ZDO7 <br />I 777-T <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />