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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYIZIP i1�-1^l -l C/A <br /> CROSS STREET S 1 1�1 L-.,�►/� APN [ V:� CJ (�/ "j PARCEL SIZE <br /> OWNER NAME <br /> ►r.IoP` L.,cLL PHONE <br /> OWNER ADDRESS <br /> rJAr^6 YA ' A16—ic CITYISTATEIGIP <br /> 9 <br /> CONTRACTOR 1 .'br1C.K 00 t IIIA C— f �il_�ly-..�L 1� PHONE � <br /> L <br /> y ,�C� <br /> f.-. r <br /> CONTRACTOR ADDRESS MSX Z.3�(f ` CITYISTATEIZIP nz JAI- ��-T <br /> LICENSE [�C-42 CIC-36 OTHER NUMBER tl� EXPIRATION DATE_ <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COordlnateS X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# fJ <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION J ENGINEER DESIGNED IALTERNATIVE <br /> C REPLACEMENT _ <br /> DESTRUCTION _ <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gaI #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG _ CAPACITY gaI #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 SYSTEM) Y�'1 <br /> G <br /> r <br /> ❑ LEACH LINES i7 LEACHING CHAMBERS �titFI��IA'ie�/ #OF LINES LENGTH OF LINES d ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 45 ft PROPERTY LINE It <br /> G <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 It <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 It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERRTYY LINE ft <br /> $ SEEPAGE PITS NUMBER t WIDTH <br /> ' I ft DEPTH G'E v ft <br /> DISTANCE TO NEAREST WELL .7u ft FOUNDATION t 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 f ES l{) ► DATE <br /> I b ► 11 <br /> AiY <br /> J <br /> ly, 1 <br /> IL- <br /> DEPARTMENT U5 -ONLY f <br /> Application Accept Date Area Employee ID#—�f� <br /> SPEC IA PERMIT-Approved h <br /> Final Inspection By Date ❑ PP Y <br /> Character of Soil to D96th of 3 Ft: Pitt {TIp Soil Character: <br /> COMMENTS 1P12 1-YA <br /> PE SC Received k#1- Amount Date Permitl Invoice# Permit ID# <br /> Cod_a INFO B Cash Remitted Service Request# <br /> Z� 3 3 . 0D Wo7�z <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 1014107 <br />