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ONSITE ATEWATER TREATMENT SYSTEM . AMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT A C L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> .IIADDRESS �`-I � - CIP6zIP .C(� ✓' <br /> 9 �x <br /> CROSS STREET / _ APN _ of T,��> PARCELSIZE <br /> -- o <br /> O INER NAME e C, 0te _ __ _ _. <br /> //_P�H/lONE/� C� ((2 <br /> - <br /> CONTRACTOR <br /> ADDRESS ,C/r J�/ �J^ CITYISTATE/21tf�y�!'�L`� tel{ I S�((` <br /> CONTRACTOR ( 7n�C 1`cC7L' I f _- _- PHONE( //�� <br /> CONTRACTOR ADDRESS�V l J `�/ r _ _CITY/STATEIZIP C <br /> LICENSE C! C-42 [11�C-36 OTHER NUMBER r 1"Z,y�— EXPIRATION DATE 7-31-17 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> Fi PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATl E <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION T KVI� <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL LI OTHER <br /> NUMBER OF LIVING UNITS:_ NUMBER OF BEDROOMS: ._. _ NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG — CAPACITY _ gal #OF COMPARTMENTS___ <br /> ❑ GREASE TRAP TYPE/MFG _ CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WEI1. It FOUNDATION IT PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE _ ,- TYPE OF PUMP_ _❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS _ #OFLINES LENGTHOFLINES ft <br /> DISTANCE TO NEAREST WELL--- ft FOUNDATION ft PROPERTY LINE It <br /> ❑ FILTER BED WIDTH _ --- _ It LENGTH__ __ ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE it <br /> ❑ MOUNDED WIDTH ft LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL __ ft FOUNDATION it PROPERTY LINE It <br /> ❑ SUMPS WIDTH ----_--_- ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE it <br /> ❑ DISPOSALPONDS WIDTH _It LENGTH It DEPTH_ it <br /> DISTANCE TO NEAREST WELL - It FOUNDATION _---It PROPERTY LINE _it <br /> ❑ SEEPAGE PITS NUMBER __ WIDTH __-- _-It DEPTH it <br /> DISTANCE TO NEAREST WELL -- It FOUNDATION _ft PROPERTYLINE_ _ 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 /> M NIMW24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNE TITLE / rGc c✓ DATE - <br /> �r� <br /> Ls <br /> 24 L <br /> i b �C <br /> e/ i <br /> DEPARTMENT U EONLY <br /> Application Accepted By Date-_$ Area -tr1 _ Employee ID#- -Lil.u� <br /> Final Inspection By Date J SPECIAL PERMIT-Approved by <br /> Character of Soil Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS 'L <br /> PE SC Received Chack#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash <br /> Remitted Service Re uest# <br /> 1/10 S�0 Q <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />