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/rk) _ . 9= /f,, =v'i-E"\ 5 w t -51-t7 Own <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT 5, ._ GALL (209)953-75.97 FOR INSPECTIONS <br />I YEAR FROM UATE ISSUEI <br />JOB ADDRESS +> ���%l��L ll l',�� CITY/ZIP S�7D' /`/�' % > 4 A /i <br />CROSS STREET 7 ! "/ /�J Gly /hell APN 7/ + v PARCEL SIZE & 7Z <br />OWNER NAME � _ tl_ -C_ TTI PHONE <br />OWNER ADDRESS ��,/L /' CITY/STATE/ZIP <br />CONTRACTOR//i7 ��%iC� '6t ('R(G - _ PHONE <br />CONTRACTOR ADDRESS /y�,�T 41-1,4zfkg CITY/STATE/ZIP 46///I/ <br />LICENSE Xt C-42 I], C-36 OTHER NUMBER �_ EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # _ BUILDING PERMIT # LAND USE APPLICATION #_ <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESK <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM Fi DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG L��11 �tr1x'1_.. CAPACITY <br />❑ GREASE TRAP TYPE/MFG _ CAPACITY <br />DISTANCE TO NEAREST: WELLp�WWV "ft FOUNDATION <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />.TERNATIVE <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />I <br />/ <br />LEACH LINES <br />LEACHING CHAMBERS <br />Permit/ <br />Service Request # <br />Invoice # <br /># OF LINES -� <br />ZI ► I 'S <br />2s <br />DISTANCE TO NEAREST WELL <br />3 <br />ft <br />FOUNDATION <br />❑ <br />FILTER BED <br />WIDTH ft <br />LENGTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />❑ <br />MOUNDED <br />WIDTH ft <br />LENGTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />SUMPS <br />WIDTH l ft <br />LENGTH <br />2ti ft <br />/ <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />❑ <br />DISPOSAL PONDS WIDTH ft <br />LENGTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft <br />DISTANCE To NEAREST WELL <br />ft <br />FOUNDATION <br />LENGTH OF LINES 2%/ ft <br />ft PROPERTY LINE ft <br />DEPTH It <br />ft PROPERTY LINE It <br />DEPTH It <br />ft PROPERTY LINE It <br />DEPTH / �) ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />I 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 />MMM 24 HQURADVANeE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED v -TITLEh <br />DATE <br />zll�P J. <br />�y r__ <br />DEPARTMEN USE ONLY <br />Application Accepted Er,—alM�� <br />„a Date t Area Employee ID#e <br />Final Inspection By H" S607"T-0 Date 2 f ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pi um Soil Character: <br />COMMENTS &aZAkTaV CMA MN A'b.PL col"MT �—AL9rjrt '-o Us'E 46�fTC-M�k T."(7 <br />PE SC Received Check#P <br />Code INFO B - Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />ZI ► I 'S <br />2s <br />3 <br />S 0 (070 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />T <br />