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t1�n ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 E.HAZELTON AVENUE-STOCKTON CASS205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL(2ft 953-7697FOR INSPECnOxs EXPIRES 1 YEAR FROM DATE ISSUED' <br /> JOB ADDRESS �-� QfcA i'•�f �+� ...CITYILia Sficickik'� Cd}�"2.l�S'_ <br /> Lh-1,.G •_ APN 1-72M�_ !3 Q— PARCEL SIZE � o <br /> CROSS STREET -- <br /> y. <br /> OWNER NAME }} PHONE <br /> 2• _- <br /> OWNER ADDRESS '{h�' 2Ga.r f=(i4 r `&0 CITY/STATE/ZIP <br /> r .$ �o T PHONE <br /> CONTAACTIDR�+�C.��i b'GKI,m�- <br /> CONTRACTOR ADDRESS _......P.5—, CITYISTATEMP ^^ -� 17�3�f <br /> LICENSE QC42 QC-6 OTHER �' NUMBEREXPIRATION DATE lT <br /> WATER TABLE DEPTH: __it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 0 PERC TEST # BUILDING PERMIT# _____ __._ LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIRIADDI ION .1 ENGINEER DESIGNED/ALTERNATIVE <br /> L; REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL SERVE, EVAESOENCE n COMME=AL Cl OTHER <br /> NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS:.--3- -.---- NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPEIMFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFC_._... _ CAPACITY gal li OF COMPARTMENTS.-- <br /> DiSTANCETONEAREST: WELL ft FOUNDATION ft PROPERTY LINE 11 <br /> ❑ LIFT STATION SIZE TYPE OF PUMP_ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> #OF LINFS LENGTH OF LINES 401 It <br /> B' LEACH LINES .I LEACHING CHAMBERS ,L <br /> DISTANCE TO NEAREST WELL? it FOUNDATION _it PROPERTY LINE .____...it <br /> ❑ FILTER BED WIDTH _it LENGTH R DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPEfrTyuNE R <br /> ❑ MOUNDED WIOTN it LFNGnI it DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE it <br /> ❑ SUMPS WroTH it LENGTH ft DEPTH B <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPF.RTYUNE ft <br /> ❑ DISPOSAL PONDS WIDTH it LFNGni ft DEF^m_- It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION •_.,..._ft PR1^oftgTYUNE._...__. H <br /> �EPAGEPITS NUNaER WIDTH �Lsfl it DEPTHp.5..... ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION _..____ft PROPERTYLINE -r It <br /> I HEREBY CERTIFY THAT I HAVE.PRF-PARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDMANCES. <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY_ <br /> INIMUM 24 N U ADVANCE NOTICE REOUIRED FOR[INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED DATE )44 13— <br /> t y <br /> - - U <br /> Q O r I T N <br /> I r <br /> ........... <br /> t� II <br /> I w <br /> ' ' t <br /> 4 <br /> r <br /> ►, DEPARTM NT D !Y <br /> Appltcation Accep Date Z _ Area a I 9 y Employee ID# <br /> Final Inspection By t Date. C SPECIAL PERMIT-Approved by <br /> Character of Soil to hof 3 Ft Pit —P SOI[Character: _ <br /> COMMENTS �1Pi <br /> PE SC Received Check Amount D Permit/ invoice ii Permit IDk <br /> Code INFO B -Ca Remitted Service Re uest a <br /> Sko o £s l 2 is <br /> ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 42.01 <br /> 4124/12 <br />