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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> 'SAN JOALIUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1869 HAZELTUN AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> r NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS '?!3q5? (�����(-- - �/F�+ CIrrTY21P : � a <br /> CROSS STREET 84 ca (7Z APN .JY�� �? _ PARCEL SIZE_ l ' p <br /> �^ r o <br /> OWNER NAME L' S im L/ `1P S au C O An' PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR _ PHONE __ <br /> CONTRACTOR ADDRESS --CITY/STATE/ZIP <br /> LICENSE D C-42 CJ 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 ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE J COMMERCIAL L 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 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED aSYSTEM) <br /> '�LEACH D<LEACHING CHAMBERS #OF LINES LENGTH OF LINES �"`� �C7 ft <br /> DISTANCE TO NEAREST WELL 46V5— ft FOUNDATION /V ft PROPERTY LINE �y a ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO `RE$� WELL ft FOUNDATION ft PROPERTY LINE ft <br /> (� WIDTH 11 ft LENGTH ! , ft DEPTH ft <br /> DISTANCE TO NEARE WELL /00 ' <br /> ft FOUNDATION ft PROPERTY LINE �� t ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH It 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 /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 <br /> SIGNED - TITLE IA/n/e" DATE C)y, tZSZ '� C <br /> I <br /> 4j- 1 <br /> DE 4RTMENT SE ONLY p� <br /> Application Accepted il� L- a ialoe: [ FmnlwPe ICI# <br /> Final Inspection By _ - Gil —___ _.___-_-_ Date ._�a� /l y rl SPECIAL PERMIT-Apo,oved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENT Q040 <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO �B r_ Cash Remitted Date Service Request <br /> # Invoice# Permit ID#� <br /> _ u A f ,® 5 00-15-7 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />