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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAOUIN 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 ' 1 CITYZPP Fie n c Nt 3 I <br /> CROSS STREET 14;rl.ar}' w4M/ APN 19j 17O (0 PARCEL SIZE <br /> 0 <br /> OWNER NAME K�('I V N�� PHONE <br /> OWNER ADDRES^S' S OCa / CITY/STATEIZIP 1 'P GN (4 N4`{�I <br /> CONTRACTOR{VQII 414-'51105110 A.4j�9SLC1 S4CS /µ�I/f T«rIC6V` (0 PHONE�o �/� ✓70 7 / <br /> CONTRACTOR ADDRESS '10 Z L.4ka q S �[I Q^I/ CITY/STATEIZIPr • � /S{„ `t O <br /> LICENSE C-42 C-36 OTHER l "J NUMBER (0100 C4 EXPIRATION DATE S-131 / 1 -7 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y / <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# A— ?OG <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED(ALTERNATIVE / <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: Fl RESIDENCE 11 COMMERCIAL I OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTT.IENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal a O�COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS 0 OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE It <br /> ❑ FILTER BED WIDTH it LENGTH R DEPTH _n <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH it LENGTH ft DEPTH A <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE fl <br /> ❑ SUMPS WIDTH ft LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION it PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH R <br /> DISTANCE TO NEAREST WELL It FOUNDATION III PROPERTY UNE It <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE WS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIM 4 NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-Z697 <br /> SIGNED TITLE '54"4 (11-01 DATE z�j—_ 2'f I <br /> CE EF T <br /> n <br /> 2 4 20;5 <br /> ulIV <br /> ME COUNTY <br /> PAHTitkEM <br /> DEPARTMENZUSEMLrq A <br /> Application Accepted By Date Area 1 Employee ID# -TJ'�SI oX'ULC4-Cx- <br /> Final Inspection By Date C.! SPECIAL PERMIT-Approved by <br /> Cha'''rac///t111er of Soll to W of 3 Ft: A PIV ump Soil Character: <br /> COpnpnENTS <br /> 1 Gym '✓ � < <br /> PE Sc Received Ch Amount DatePermit/ Invoice# Permit ID# <br /> Code INFO BY ash Remitted Service Request# <br /> If <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4124112 <br />