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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E W'ESER AVE-3"FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS D �! CITY/ZIP <br /> CROSS STREET Y air 1""'� APN ZSo—100 PA CEL SIZE - Y <br /> I � n p <br /> OWNER NAME ��I t( /l Gb� PHON + 2s 447i <br /> OWNER ADDRESS 1 t0 S A G ./ CITY/STATE/ZIP--rr " <br /> CONTRACTOR A4,0 PHONE 3 <br /> CONTRACTOR ADDRESS CrrY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# 05 00 ZZ <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAHLADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBEROF LIVING UNIT'S: 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 /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O FILTER BED WIDTH ft LENGTH ft DEPTH ft C <br /> D[SrANCE TO NEAREST WELL ft FOUNDATION It PROPERTY UNE It <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ift <br /> ❑ DISPOSAL PONDS WLDTH ft LENGTH ft DEPTH it 0 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH ft . <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINT: ft r <br /> 1 EBY CERTIFY THAT I HAVE PREPAREDTHISAPPLICATION AND THE WORK WILL BE DONE,IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> GTLAn ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. - — •,�.y,p' <br /> Sl 7'C 1r MINIM T4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL.(209)953•\7697 T <br /> SIGNED TITLEe-- —S 4 — DATE I2 •�^a <br /> wcaans. <br /> 12ep' <br /> TNflY AaNSKa S � <br /> 10 ac OE111CP nRJ ']'aOtiY ?,..tlD' 7— I YJ' <br /> .DI AO== PARCEL '1" <br /> aPo•ysK 1D{ra 7.Da anI[S a — <br /> P n <br /> ,se-aa 11' eco• ' S N N O N <br /> 1 ti <br /> wra�vuw uN>.- <br /> w seeavv uw <br /> ro-sao-u rss•aw-oa <br /> para y JLLP ObiYH.a+eYfN <br /> '✓-�� r[aaix u <br /> KAY <br /> �DEaPPARTMENT USE ONLV --lox r{q1l <br /> Application Accepted B ' Date (JtyS Area Empioyee iD# <br /> Final Inspection By , Date 2 7 BEDS 13 SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept oT3 Ft: Pit/Sump Soil Character: <br /> COMMENTS Ot LVA?Z& 1() A 6,t//5 40"-76$>' A,'15e <br /> PE SC Received Chec Amount Dau Permit/ Invoice PermitID# <br /> Code INFO B ash Remitted Service R uert# <br /> Z w 17- <br /> 42-03.001 ONSITE WASTEWATER PERMIT <br /> 12/22"!003 <br />