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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 AjG "'te /`yam CITY/ZIP ML8y?;D0 <br /> �J Q /- t7 <br /> CROSS STREET `��•/Jl//p�Cs� �i�C... APN ©l1'- L� ^ ( -( PARCEL SIZE 0 .ICS > <br /> OWNER NAME���f�� lnx�s�.� PHONE vi <br /> OWNER ADDRESS /S0 O / CITY/STATE/ZIP Ai:Aoa <br /> CONTRACTORl N/JLI'l� J/�� �L PHONE yy- -'6/y�/'L� , <br /> CONTRACTOR ADDRESS 3752 _ - >✓w //��/� �z CITYISTATE/ZIP ✓�lG�.� <br /> LICENSE C 42 ❑',IC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: 1 D ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: PG-RESIDENCE ❑ COMMERCIAL 11 OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG �.144: CAPACITY gal #OF COMPARTMENTS_ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL� ft FOUNDATION /Q/ ft PROPERTY LINE 14W f ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT '❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> AL LEACH LINES LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION :5-0, ft PROPERTY LINE 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 /> ID SUMPS WIDTH ft LENGTH It 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 ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER lz� WIDTH V" ft DEPTH / ft <br /> DISTANCE TO NEAREST Wf_I_L_ ft FOUNDATION 1617 ft PROPERTY LINE 7GG 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 FLOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE / <br /> V ON <br /> N E <br /> Q PART 'ENT SE NLY <br /> Application Accepted ByDate Area Employee ID#� <br /> Final Inspection By Date ` ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept of 3 Ft: Pit/ umb Soil Character: <br /> COMMENTS <br /> PE SC Received eck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cas Remitted Service Request# <br /> 4-®rl <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114118 <br />