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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 CALL 209 943- 697FOR INSPECTIONS E PIRES 1 Y FROM DATE ISSUED <br /> 4SCROJOB ADDRESS -CITY/ZIP d4-- <br /> GROSS <br /> SS STREET APN to .7 l ta0 A PARCEL SIZE t+ ! j <br /> OWNERNAMEI/JT..[ice ' /�/�i ;//LJ PHONE � f � L vi <br /> OWNER ADDRESS CITY/STATEOP <br /> CONTRACTOR /G �,.6� r1 / lJyr Q�J I+I L-�IJCi� PHONE <br /> CONTRACTORADDRESSADDRESS �^ CITY/STATE21P�7G ''��77t� Gri ��� <br /> LICENSE /Se! C-42 C,-C-36 OTHER NUMBER �J 017OAXPIRATION DATE <br /> WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> i <br /> G PERC TEST # BUILDING PERMIT#T==LAND USE APPLICATION# <br /> TYPE OF WORK: - NEW INSTALLATION-7- Q Lt'S1 REPAIRIADDITION ENGINEER DESIGNED IALTERNATIVE <br /> REPLACEMENT - OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE Ll COMMERCIAL V OTHER /'A <br /> NUMBER OF LIVING UNITS; NUMBER OF BEDROOMS: ) NUMBER OF EMPLOYEES; <br /> SEPTIC TANK TYPE/MFG�/,�''j" (_]� CAPACITY / 1� gal #OFCOMPA.RTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OFCOMPA.RTMENTS <br /> DISTANCE TO NEAREST: WELL R FOUNDATION " <br /> it PROPERTY LINEft <br /> A LIFT STATION SIZE TYPE OF PUMP__.. 13PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> C LEACH LINES LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES 7 ft <br /> < 7 <br /> DISTANCE TO NEAREST WELL__ R FOUNDATION_ ft ft PROPERTY LINE_._4�� � R <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE it <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE R <br /> Cl DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FFOUPDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER 12 WIDTHy it DEPTH ._�r it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION e � ft PROPERTY LINE _�� it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLLIICATIOION.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 /> MINIMMfl 24 HQU",DVA&E NOT E REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 f <br /> SIGNED_ J TITLE Cr L� DATE <br /> r <br /> 2. <br /> T41 <br /> e <br /> I <br /> _l <br /> ' > � - <br /> - _ _ • 5M <br /> -w , <br /> - 1 DEPARTMENT USE NLY f <br /> Application Accaptod Date i D Z 5 <f Area P4 F Employee ID# <br /> Final inspection /( _ Date �G _Z2.S G SPECIAL PERMIT-Approved by <br /> Character of Sol[to D pth of 3 Ft: PitlSump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#1 Amount Date Permit/ <br /> Code Permit 10# <br /> Code INFO B Cash Remitted _ Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 412402 <br />