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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)46B-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7 'L /✓• a f!' e 14/6 CITYIZIP r�G��� i•-!� /!! <br /> CROSS STREET APN �`� �� ✓ PARCEL SIZE Y <br /> OWNER NAME / LC 'a I� J /I H"� n ^ p 7 T <br /> PHONE .0 1 d — / 7-2 2. <br /> OWNER ADDRESS ' 3 7 w ' '" �/ / CITYISTATE/ZIP <br /> CONTRACTOR ' % / �( 1y1� PHONE /"r ry / <br /> CONTRACTOR ADDRESS 1� / CITYISTATE/ZIP <br /> LICENSE 4 G-42 C-36 OTHER NUMBER Ifly Y 6/E%PIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION-yc Lf11-i ixi REPAIRIADDITION ENGINEER DESIGNED/ALTERNATIVE, <br /> REPLACEMENT A to - OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ✓RESIDENCE r I `111T COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: "'PIN641IR OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG / CAPACITY �...=V(' gal #OFCOMPARTMENTS 21 <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal 9 OF COMPARTMENTS <br /> DISTANCE To NEAREST: WELL ft 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 #OF LINES LENGTH OF LINES ft <br /> r�[QAk1`[ //f /�i VIRFI�nDLISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILIEFi BEDTH it LENGTH fl DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE R <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE it <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it <br /> ❑ SEEPAGE PITS NUMBER WIDTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE It <br /> 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 24 HOUR 62VANCE NOTICE RE UIRED FOR INSPECTIONS-PLEASE CAL 09 953-7697 <br /> n <br /> SIGNED/ /Ii �ifi'C� 411/ ci'vDATE <br /> 1pr <br /> p <br /> 15 <br /> C UNTy <br /> -Q Ama L N - L <br /> ENT <br /> 1 <br /> I <br /> h t <br /> c ; - - -- - - - - -- <br /> 1.4•,.)(f ef,S " f P'! `1' " DEPARTMENT SE ONLY <br /> Application Accepted By o _-D3te Area I: Employee ID# <br /> Final Inspection By Date % SPECIAL PERMIT-Approved by <br /> Character of Soil to D6pth of 3 Ft: it/Sump Soil Character: <br /> COMMENTS <br /> 221 'ye- <br /> PE SC Received Amount Permit/ Invoice# Permit ID# <br /> Code INFO 8 ash Remitted Date Service Re uest# _ <br /> fWaK <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />