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-Z,%Yc,A 5 L k,Y IL-1-7— 1U 0 - \ 1 ` ` <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(249)468-3420 <br /> NON-REFUNDABLE PERMIT CAL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 1 -1, CITY/ZIP U <br /> CROSS STREET noer <br /> APN lq3254 a 51 PARCEL SIZE <br /> OWNER NAME E Va CJ I PHON 1�_0f 4;1, -]/—0-72_0Ro j <br /> h <br /> OWNER ADDRESS L CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE L7C-42 ❑' -C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> LL1 FERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESI NED/ALTERNATIVE, <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION L <br /> INSTALLATION WILL SERVE: 1.1 RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL it FOUNDATION it PROPERTY LINE it <br /> ❑ LIFT STATION SIZE TYPE OF PUMP 0 PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> O LEACH LINES I I LEACHING CHAMBERS #OF LINES LENGTH OF LINES it <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it <br /> J FILTER BED WIDTH it LENGTH it DEPTH it <br /> DISTANCE To NEAREST WELL it FOUNDATION it PROPERTY LIN it <br /> ❑ MOUNDED WIDTH ft LENGTH it DEPTH ffAyP4it <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LI it <br /> ❑ SUMPS WIDTH it LENGTH it DEPTH ey it <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROP TY LINE it <br /> El DISPOSAL PONDS WIDTH it LENGTH it DEPTH aI2914QUIN nn„N�._. it <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPS � flJr ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH it DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS IONS-PLEASE CALL 209 953-7697 <br /> L <br /> SIGNED TITLE U yr,-er, DATE I`Jxll <br /> #1 1 <br /> • [)EPA RTMENT SE bNL Y 1 <br /> Application Accepted Date Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PitfSump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> 6- <br /> 42.01 ONSETE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4124/12 <br />