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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 <br />GALLZU.9y0J-f0.9f FOR INSPEGTIUNS <br />MAF[Kts 'I TtAK I-KUIVI UAIt IJJUtI <br />JOB ADDRESS �Z17 _3 N <br />#E 0kE4 44N <br />,n <br />LP <br />E CITY/ZIP D / <br />7 fi 32. <br />CROSS STREET L.I BEAQT✓ <br />"4,0 <br />APN 0,05-- AP -,Q <br />PARCELSIZE <br />OWNER NAME Ro BERT <br />r. So klCw <br />- ® nO - 3 fad <br />OWNER ADDRESS 4:119 it <br />N. 6454CO&CE /ANE <br />/ <br />CITY/STATE/ZIP LnD <br />,,PHONE�M!g <br />I f5l u - <br />CONTRACTOR 4C <br />SUMPS WIDTH <br />PHONE <br />ft <br />CONTRACTOR ADDRESS P <br />D <br />CITY/STATE/ZIP <br />/ I1Q LOC _ 1A 4?rMl <br />ft <br />LICENSE ❑❑C42 ❑❑C-36 <br />OTHER Q • ` • <br />NUMBER 617r4-72 EXPIRATION DATE <br />�� <br />WA ER TABLE DEPTH: eai ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST #_4 BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION LJ REPAIR/ADDITION Li ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION _ <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />❑ LEACH LINES ❑ LEACHING CHAMBERS <br />DISTANCE TO <br />NEAREST <br />WELL <br />ft <br />FILTER BED WIDTH <br />ft <br />LENGTH <br />DISTANCE TO <br />NEAREST <br />WELL <br />ft <br />MOUNDED WIDTH <br />ft <br />LENGTH <br />DISTANCE TO <br />NEAREST <br />WELL <br />ft <br />SUMPS WIDTH <br />ft <br />LENGTH <br />DISTANCE TO <br />NEAREST <br />WELL <br />ft <br />DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br /># OF LINES LENGTH OF LINES <br />FOUNDATION <br />ft <br />FOUNDATION <br />ft <br />FOUNDATION <br />ft <br />FOUNDATION <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LLNE <br />DEPTH $� ft <br />ft -- PROPERT U/ ft <br />DEPTH /''D MF UN ft <br />ft PROPERTY LINE R! ft <br />❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION 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 />%I STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />SIGNED <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Dept of <br />COMMENTS `r W <br />DEPARTMENT USE ONLY <br />Date 2 Area l Employee ID# c <br />Date ❑ SPECIAL PERMIT -Approved by <br />2 /� PRISump/SoilpCharacter: <br />To n. / _> C O I14 rv� i /l <br />PE SC Received <br />Code INFO B <br />Che <br />ash <br />Amount Date Permit/ <br />Remitted Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />T <br />a <br />Y <br />d <br />d <br />Cn <br />K <br />