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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HaRelton 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 ADORES, —3/J� ��ffl.''/ �'�J. CRYZP <br /> CROSSSTREET y�b2e"i<t /`a/o APN�^'r- 0 -n� PANCELSRE �-1 <br /> OWNER NAME_-&0'4./R /S H'1'✓'C CSC YL PHONE P <br /> OWNER ADDRESS // ,./- CRY/STATEMP 6 <br /> CONTRACTOR (�tM,�-e/-T V/tl� /�y/C PHONE /_ <br /> CONTRACTOR ADDRESSy Y D�SW"1 -it CITY/STATFJZIP 6001, <br /> Y r <br /> LICaNSEi4C-42 QC-36 OTHER NUMBER SIOyS pIMTION DATE <br /> WATER TABLE` DEPTH: It GEOGRAPHICALINFORMATIOH: CDordinates X Y <br /> ❑ PERCTEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADOITION C ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: X RESIDENCE ❑ COMMERCIAL 'P 11 OTHER <br /> NUMBER OF LYING UNITS: I LNUMBER OF BEDROOMS: 3 NUMBEROFEMPLOYEEB: ^^ff <br /> ❑ SEPTIC TANK TYPE/MFG �Tfi,Sji+w CAPACITY 00 yil #OF COMPARTMENTSo• <br /> ❑ GREASETRAP TYPE/MFG�7 CAPACITY Bal #OFCCMPARTMENTS <br /> DISTANCE TO NEAREST: WELL It FOUNWTIDN ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKGTXPLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS -25- #w LINES LENGTH OF LINES 14O0 / It <br /> DISTANCE TO NEAREST WELL POO It FOUNDATION ft PROPERTY UNE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE it <br /> ❑ MOUNDED WIDTH R LENGTH it DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE it <br /> ❑ SEEPAGE PITS NUMBER WIDTH fl DEPTH R <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE If <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 REGULA710NS OF SAN JOAQUIN COUNTY. <br /> MINIMUM U HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> L-PLEASE CALL(209)953-7697 <br /> SIGNEDA TITLE DATE <br /> 3 S <br /> T <br /> ED <br /> ' Ir012 <br /> CUNTY <br /> El Vil ON AENITAL <br /> THEN <br /> DEPARTMENTU ON V <br /> Application AccaPtetl B Date Area Employee ID# <br /> Final Inspection By Date / / ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil To Depth of 3 Ft P Hump Soil Character. <br /> COM ENT, <br /> / <br /> PE HC Received AmountDatParmftl Invoice% PermttlD# <br /> Coda Iwo B Cash RamKted Servlu oast% <br />