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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)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _..:,_.__ - /', i LIQ. - 7 <br /> -_ - .� _.-.. _.. _.CITY21P <br /> CROSSSTREE7i' APN_ _-__........_.-_____PARCEL SIZE <br /> ? <br /> x_ r _ <br /> OWNER NAME._ �• i /;1„_ E. �'Ldn nn v i >,v PHONE <br /> OWNER ADDRESS _ CITY/STATE/ZIP <br /> CONTRACTOR 'GA i/� .�' id .If_,�c �- PHONE <br /> /tel' <br /> � ff <br /> l� <br /> CONTRACTOR ADDRESS %�J'_'�_% -.__ /"[�c�/ L. _ CITY/STATE21P <br /> LICENSE I�C-42 IAC-36 OTHER..__. NUMBERi��,_�. _Y`. EXPIRATION DATE,.__ <br /> WATER TABLE DEPTH: IT GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST N__----_--_.-___-_. ____. BUILDfNG PERMIT H _ _ LAND USE APPLICATION <br /> TYPE OF WORK: k` NEW INSTALLATION REPAIR/ADDrnoN ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE C COMMERCIAL i OTHER _ <br /> NUMBER OF LIVING UNITS: - ___,.___ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> GI SEPTICTANK TYPE/MFGCAPACITY <br /> / _ Jal NOF COMPARTMENTS <br /> ..... ° 9 - <br /> >0 GREASE TRAP TYPE/MFG _ g L _ CAPACITY_`y._� gal NOF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL It FOUNDATION >__ -__ it PROPERTY LINE It <br /> ❑ LIFT STATION SIZE _-_ TYPE OF PUMP -❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> CI LEACH LINES LEACHING CHAMBERS N OF LINES_ LENGTH OF LINES_- It <br /> DISTANCE TO NEAREST WELL It FOUNDATION -fl PROPERTY LINE_ It <br /> ❑ FILTER BED WIDTH _____It LENGTH -__- ___ ft DEPTH R <br /> DISTANCE TO NEAREST WELL __ R FOUNDATION _it PROPERTY UNE It <br /> ❑ MOUNDED WIDTH _.__,_. IC LENGTH f( DEPTH it <br /> DISTANCE TO NEAREST WELL _. ft FOUNDATION It PROPERTY LINE_ _ It <br /> ❑ SUMPS WIDTH ._ ____ It LENGTH _ _ __ 1t DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE K <br /> Cl DISPOSAL PONDS WIDTH ^ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL____-,___//it/FOUNDATION It PROPERTY L)41E H <br /> `�' <br /> SEEPAGE PITS NUMBER WIDTH /___ ft DEPTH _tt <br /> DISTANCE TO NEAREST WELL___-in_ __ It FOUNDATION- i -- it PROPERTY LINE - R <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ..`-.."y} 5"sf+ - . -• - TITLE._ _�__.�----- - ------ DATE---- ------- <br /> 1 <br /> 111 AITIE. AUL-1 I <br /> i <br /> li <br /> 1 <br /> HDE PA M <br /> I <br /> - <br /> DEPARTMENTUSEONLY <br /> Application Accepted By _. - Date ;. ._..:.--- Area --___._ Employee IDN <br /> Final Inspection By Date _ I1 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft:---- - Pit/Sump Soll Character: .____ <br /> COMMENTS <br /> PE SC Received _._.CheckNt Amount Date Permit/ Invoke N Permit IDN <br /> Code INFO B Cash Remitted Service Request N <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4124/12 <br />