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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ? <br /> JOB ADDRESS 9 dr), tRa-,co Aizz, CITY/ZIP <br /> CROSS STREET <br /> j/ �C� APN 6 ✓V PARCEL SIZE /). d <br /> OWNER NAME{/\l ���� PHO(N�E,(eSCJ,/ J, <br /> OWNER ADDRESS� 0 1�-%y/YLIrLJ CITY/STATE/ZIP (SC.� <br /> CONTRACTOR 1 1 1 I j4,t'�/ /�•lekc PHONE <br /> CONTRACTOR ADDRESS A� TC)C�'1C �S�. CITY/STATE/ZIPCM f''�t�� !i✓CI `i.5 3�i <br /> LICENSE ❑0C-42 110C-36 OTHER i NUMBER�„� 5� EXPIRATION DATE—' 07 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: L NEW INSTALLATION REPAIR/ADDITION L ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCI L ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> Ll SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPAPfT T4 2ala_ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COSW3WCTS � LS <br /> DISTANCETONEAREST: WELL ft FOUNDATION ft PROPERTdI(I�VTL�u/R0h/ C0_UNrY ft <br /> L2 LIFTSTATION SIZE TYPE OF PUMP O PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCA�Fa � <br /> LEACH LINES Q11 EACHING CHAMBERS 6-1, #OF LINES� LENGTH OF LINES 40' ft <br /> DISTANCE TO NEAREST WELL f,'.-Y',P'C., ft FOUNDATION ft PROPERTY LINE 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 NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> �EEPAGE PITS NUMBER WIDTH _3(1 11 ft DEPTH�j-( ft <br /> DISTANCE TO NEAREST WELL? Uhl,,C, 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 ?HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-76997 <br /> SIGNED TITLE C15O�l�t.{,fes DATE <br /> .00 <br /> -7000, <br /> RTMENT S LY <br /> Application Accepted B DateArea Employee ID# J� <br /> Final Inspection By Date i217 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 F.. Pit/Sump Soil CP atter: <br /> COMMENTS—:�z=. h) <br /> PE SC Received CCJwak#r Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Cash Remitted Service Request# <br /> 2 �Z I <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />