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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAM 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 75-0 G(/ee- CITY/ZIP <br /> CROSS STREET �r Y 7G�"YVG APN «c PARCEL SIZE y <br /> d <br /> /r� �/ d <br /> OWNER NAME- D✓7,VJ / l//l1 SO W PHONE 3l y �i j'96 <br /> OWNER ADDRESS /YAW! / CITY/STATE/ZIP <br /> CONTRACTOR CU�htn L � __ ��H L PHONE 3 Gr!-szi z.7 <br /> CONTRACTOR ADDRESS �l�OIG/CeraJ y�/s-" I�� CITY/STATE/ZIP S <br /> LICENSE C,-42 ❑❑C-36 OTHER NUMBER y� yS- EXPIRATION DATE%GAnoC - <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION PJ REPAIR/ADDITION D ENGINEER DESIGNED/ALTERNATIVE <br /> LI REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: , // NUMBER OF BEDROOMS: :3 NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 16y, i s CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES�_ LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL fGa'J f ft FOUNDATION 5V ft PROPERTY LINE SZ> ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL �7it FOUNDATION ft PROPERTY LINE ft <br /> J <br /> SEEPAGE PITS NUMBER O WIDTH r ft DEPTH <br /> DISTANCE TO NEAREST WELL /5V'O-- ft FOUNDATION ft PROPERTY LINE ft <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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE Orr <br /> 011 A <br /> Ewl/N <br /> y <br /> 1VTj <br /> N <br /> DEPARTMENT NLY <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date 101,36 1 All ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS �,� <br /> PE SC Received eck#/ Amount Permit! <br /> Code INFO B Cash emitted Date Service Request <br /> # Invoice# Permit ID# <br /> c'7 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14118 <br />