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tl 7i�- 861-9 <br /> r1, Tl <br /> ONSITE WASTEWAT TMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZEL TON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 09 953-7 F R INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS - -a 7sU /1. 1-,wel .J+Cr�.n�,.I <br /> APN___-_-/ C. PA_R_C—E.L SIZE <br /> E5CROSSSTREETLrr <br /> _. <br /> 0 <br /> OWNER NAME___ PHONE_.-._..�- i <br /> OWNER ADDRESS ✓ l O `� CITY/STATE/ZIP <br /> __ Q <br /> CONTRACTOR _g C I _ /w�, (J 1, PHONE-_ 1�' ',1I/O 5,.4/Z / <br /> CONTRACTOR ADDRESS 9,5-0 C> L .SK ncs /LCITY/STATE/ZIP y�1a_�_C/j _ �6g3 <br /> LICENSE I C-42 i l�IC-36 OTHER- _ - _ NUMBER D -EXPIRATION DATE_ <br /> WATER TABLE DEPTH: __ _ it GEOGRAPHICAL INFORMATION: Coordinates X __ Y <br /> [I- PERC TEST #___- BUILDING PERMIT# _ _ ___ LAND USE APPLICATION#_ <br /> TYPE OF WORK: 7�, NEW INSTALLATION REPAIR/ADDITK)N ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION _ <br /> INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL I 1 OTHER <br /> NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS:__ NUMBER OF EMPLOYEES: <br /> 2K SEPTIC TANK TYPE/MFG W-0 r J L_ _ _ CAPACITY DO _ gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG __ _ CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL __. It FOUNDATION It PROPERTY LINE _ _It <br /> El LIFT STATION SIZE _ .TYPE OF PUMP__._ __.. ❑ PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> Or'LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES_ SAO It <br /> DISTANCE TO NEAREST WELL O f r <br /> _�� ft FOUNDATION �o''�' _fl PROPERTY LINE •rOa i It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE To NEAREST WELL___ it FOUNDATION it PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH _ft LENGTH _ ft DEPTH It <br /> DISTANCE TO NEAREST WELL ___. - it FOUNDATION It PROPERTY LINE II <br /> ❑ SUMPS WIDTH it LENGTH_ ft DEPTH it <br /> DISTANCE To NEAREST WELL __ It FOUNDATION -_.it PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH _.__- ___ _ -ft LENGTH__-_ _ __. _ft DEPTH____ it <br /> 0"' DISTANCE TO NEAREST WELL_____7ft FOUNDATION_ it PROPERTY LINE------.. ft <br /> 0 SEEPAGE PITS NUMBER_-A____ WIDTH j 6 rI ft DEPTH _R <br /> DISTANCE TO NEAREST WELL I�O' ft I OUNDATION_ 60 r it PROPERTY LINE ,$bO 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 /> MIN UM 24HOURADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLEOwn __. _ DATE <br /> NA <br /> of <br /> I <br /> J N <br /> YJ O <br /> . I t <br /> � E <br /> IN nf <br /> i r <br /> LLL <br /> - - -- - — - - - -- - -- - -- <br /> DEPARThlC USE ON <br /> Application Accepte S �_. .. Rate(';-/, -/17Y-- Area Employee ID#4&'2 .. <br /> 1� <br /> Final Inspection By Date _ ___ (I SZIA PERMIT-Approved by <br /> —--- — <br /> Character of Soil t De_ of 3 Ft:____..—_ Sump Soll Characte <br /> COMMENTS ._ <br /> - �__-_ -' _71nvoIce# <br /> _ -PE SC Received Check#/ Amount Perm1UDate Permit ID#Code INFO B Cash RemittedService Re uest# _-I Sa---- —---T k3 �t � i ce! 1 '�Y 1 3 144 7. <br /> �O al n 5�44_- 336!%3 ave- <br /> 42-01 / ONSITE WASTEWATER TRTM,., _ _.EM PERMIT <br /> 4�4112 �Y� <br />