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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 I^ N CALL 209 953-7697 FOR INSPECTIONS��I�.y� EXPIRES/I YEAR FROM DATE ISSUED <br /> JOB ADDRESS II(,e'71 E 14pjq ALIC !},_CIT�Yy/ZIP_V{�/If/A.M1 'lS ALIS N <br /> CROSS STREET J=BI-E y 4VO' APN `A �Ja 00 PARCEL SIZE > <br /> OWNER NAME J///N//�`'�V�y���4e�++�'.�7 PHONE <br /> OWNER ADDRESS/ /�a7/T�['K CITY/STATE/ZIP L� Q <br /> CONTRACTOR t/ 5 e04wR" C4w7z PHONE 4 <br /> CONTRACTOR ADDRESS �DY 9(f CITY/STATEIZIP G/R '"'✓Z- �� r n' <br /> LICENSE ❑KG-92 0 <br /> CIC-36 OTHEfl NUMBER`- EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> I PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> _ REPLACEMENT LL 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 /> A/SEPTICTANK TYPE/MFG 10 CAPACITY hDa VM gal #OFCOMPARTMENTS 2 <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> a DISTANCE TO NEAREST: WELL <br /> r it FOUNDATION 1t PROPERTY LINE it <br /> ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEA <br /> .S;W MMES LEACHING CHAMBERS #OF LINES LENGTH OF LINES iTI/ it <br /> DISTANCE TO NEAREST WELL It - FOUNDATION ft PROPERTY LINE/ it <br /> ❑ FILTER BED WIDTH it LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST .WELL it FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH It LENGTH it DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE k <br /> ❑ DISPOSALPONDS WIDTH It LENGTH ft DEPTH It <br /> DISTANCE TONEAR ST WELL k __FOUNDATION k PROPERTY LI It <br /> SEEP PITS NumeEfl R . WIDTH __ k DEPTH _ it <br /> DISTANCE TO?EAR WELL ID/y'I it IION ft PROI ER ft <br /> 1 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 /> MMM4 HO DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 <br /> SIGNED TITLE__ DATE N-7461 <br /> 5�"e-57 Ali <br /> I <br /> DEPARTMENT U E O Ly <br /> Application Accepted By - DateArea Employee ID# <br /> Final Inspection 1 Date_� '+� 11SPE AL PE MIT-Approved by <br /> Character of Soil toIledilb of 3 PruSump SoR Character: _ <br /> COMMENTS /J / / /J <br /> �1i pj/S rI /y bL G/�Q21I�4AfL'l� <br /> E SC Received Check#/ Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit lD# <br /> 42-10 r o �b of ,,:3; 01 kP <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />