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� 0, 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 CALL 209 953-7697 FOR INSPECTIONS ` EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS W CITYIZIP lVLCC V, n <br /> CROSS STREET I CL vVI■✓1 e APN 217- '� r''' PARCEL SUE V.7 a A c <br /> c <br /> y1 1 F <br /> OWNER NAME-.- ��II//GL�//1 /)/ 1 w l.-. I_,,`�d.. PHONE <br /> /L/ <br /> OWNER ADDRESS y[_.,�V e Oyv!F CeyCITY/STATEIZIP <br /> CONTRACTOR C. c/.l'yt/. �(7�� (/� _ PHONE _ y��/� (�'�'//�} <br /> CONTRACTOR ADDRESS � I Z V(/'� `SIO C 11-5 �-_✓n� __CITY/STATE/ZIP .+r L IJ�Q� 5' ^'� <br /> LICENSE QC-42 ❑C-36 OTHER NUMBER 9011 3q EXPIRATION DATE___ ( -3(- 20 <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 L REPAIR/ADDITION [: ENGINEER DESIGNED/ALTERNATIVE <br /> C REPLACEMENT I I OUT-0F-SERVICE SEPTIC SYSTEM Y, DESTRUCTION <br /> INSTALLATION WILL SERVE: L RESIDENCE J COMMERCIAL ❑ OTHER <br /> NUMBER OF LMNG UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:___..,.__ <br /> ❑ SEPTIC TANK TYPEIMFG _ CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP _❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES Ll LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WEIL ft FOUNDATICN_ R PROPERTY LINE It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL _ It FOUNDATION 11 PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE It <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH_ _ _ ft DEPTH It <br /> DISTANCE TO NEAREST WELLft FOUNDATION It PROPERTY LINE 1t <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH _ M <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE _ It <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 /> MINIM 24 HOUR ADaNCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE f N t'N I��+�1 f DATE Y-16 41 <br /> i <br /> OTI <br /> I <br /> — — Nn <br /> AE N IH <br /> DEPARTMENT USE ONLY <br /> Application Accepted By r Date / I_3_. Area !9� 9�1 Employee ID# <br /> Final InspectionBy ���Date 11SPECIAL PERMIT-Approved by <br /> Character of Soil to hof 3 Ft: Plt/S cter: ._. <br /> COMMENTS <br /> PE SC Received heck#/ Amount Date Permit/ Involco# Permit ID# <br /> CBY <br /> IN,. Remitted Service Request# <br /> s � � __- <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4!24/12 <br />