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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 2 ---- <br /> CROSSAPN <br /> PARCEL SIZE <br /> STREET _ -(- --------- <br /> a aev f- 6�✓/C _ -_ __ _ __..__...-PHONE_T �il �GJ n <br /> OWNER NAME '—- <br /> �3_S, CITYtSTATE21P c(,, C �L ` -- <br /> OWNER ADDRESS _ __.._ <br /> > fc n.c ----- --- - - - PHONE- --33"j-/3`3 <br /> CONTRACTOR [ ` • <br /> CONTRACTOR ADDRESS f L•---- -- CITY/STATE/ZIP _- <br /> L J- 2 <br /> LICENSE tC-42 ':.: C-36 OTHER NUMBER -EXPIRATION DATE_.-? <br /> W ATEA TABLE DEPTH: <br /> -- ___ .it GEOGRAPHICAL INFORMATION: Coordinates X___._--.-___.-_--- Y.------- <br /> _ <br /> PERC TEST #. BUILDING PERMIT# ___ LAND USE APPLICATION <br /> _T__ <br /> YOF WORK! NEW INSTALLATION <br /> REPAIRlAODITION ENGINEER DESIGNED,ALTERNATIY <br /> REPLACEMENT - OUT_OF-SERVICE SEPTIC SYSTEM 4Z DESTRUCTION <br /> COMMERCIAL OTHER <br /> INSTALLATION WILL SERVE: � RESIDENCE <br /> _ <br /> _ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ' NUMBER OF LIVING UNITS:__.__-__ ---- _-��--- -` <br /> ❑ SEPTIC TANK TYPE/MFG ____ - __ _ _ CAPACITY_—______ gal #OF COMPARTMENTS-- <br /> ❑ GREASE TRAP TYPE/MFG <br /> CAPACITY gal #OF COMPARTMENTS_,--_-it FOUNDATION it PROPERTY LINE --__- <br /> —_-_- —_---._._. ___ _ ---------- <br /> it <br /> DISTANCE TO NEAREST: WELL -. - -- <br /> ❑ LIFT STATION SIZE TYPE OF PUMP___. .._ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES_ LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL.-___. <br /> it FOUNDATION -__._.It PROPERTY LINE___ it <br /> ❑ FILTER BED WIDTH _ _ It LENGTH __-__.-___---ft DEPTH_ -_--it <br /> DISTANCE TO NEAREST WELL------ it FOUNDATION _.__-__-it PROPERTY LINE—_.___--it <br /> ❑ MOUNDED WIDTH It LENGTH--___.- __fl DEPTH _ __ it <br /> ----------- <br /> DISTANCE TO NEAREST WELL_-------- _ It FOUNDATION ---_._.It PROPERTY LINE it <br /> ❑ SUMPS WIDTH ..-_ -----it LENGTH___-__.__-_- _ft DEPTH it <br /> DISTANCE TO NEAREST WELL_ it FOUNDATION- -._ff PROPERTY LINE it <br /> ❑ DISPOSAL PONDS WIDTH. _..-_.-_.It LENGTH _ft DEPTH_ it <br /> DISTANCE TO NEAREST WELL_- _ it FOUNDATION __.__—.___f! PROPERTY LINE_ it <br /> Z] <br /> it <br /> ❑ SEEPAGE PITS NUHeER_-.- ....... WIDTH--_--__-_-- --._-11 DEPTH. ------it <br /> DISTANCE TO NEAREST WELLit FOUNDATION R 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 4 O AD ANC.E NOTICE REOUiRED FOR INSPECTIONS PLEASE CALL209 9 697 <br /> SIGNEDDA <br /> i <br /> -_ � - _ S N d Q l C <br /> -- - - <br /> _Tff <br /> REP_ARTMENT USE O I.YI ` <br /> Application Accept _ i, Date7 r-'Area ` Employee <br /> � _ 1 L' 1 ._-- Y <br /> DafeSPECIAL PERMIT App:cved by <br /> Final Inspection <br /> By - -;ry/ <br /> Character of Soil to D of 3 Ft:_ PiU3ump Soil Character: _ <br /> COMMENTS L f��_wT� �tS ���• c+ f��a-v� fly"' �L1�'ItF1 iYl��r{-r;_- <br /> `i PE SC Received ck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted- _ _ Service Request a <br /> 'A22 `� io�s <br /> ONSITE WASTEWATER TRTMNT SYSTE=M PERMIT <br />