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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 .28pp/GO S. QJ R(� R D CITY/ZIP //ZACV S�O L/I <br /> y <br /> h] <br /> CROSS STREET LIA//vE A P N 1 SS-OHO_ 6 4- PARCEL SIZE L <br /> OWNER NAME (i&AR LE f / ET. - PHONE 2?d 9- Gal ('g <br /> OWNER ADDRESS /.21 D�GAIVEV AVE - CITY/STATE/ZIP OIZI-A/✓� �� 3a S1o� <br /> CONTRACTOR CN> SNE V C'O N 5 Q L7,," PHONE <br /> T <br /> CONTRACTOR ADDRESS �. CJ _ [j 0 Y 't CITY/STATE/ZIP I a R LO LIL1 CFS q5739?/ <br /> LICENSE ❑❑C-42 ❑❑C-36 OTHER (2 NUMBER (i' L�]q EXPIRATION DATE <br /> WA TABLE DEPTH: ' 40 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION I 1 REPAIR/ADDITION 0 ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT _1 OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: 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 /> 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 ft FOUNDATION 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 /> ❑ 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 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL 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 /> MINIA 48 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 1 <br /> SIGNED TITLE G/d/L E/V(flAIF_E/? DATE 3 /° ZG <br /> AN <br /> A <br /> fd <br /> Oq <br /> H N <br /> DEPARTMENT USE ONLY _ aRP „� <br /> Application Accepted E3y Date 3 ZO Area Employee ID# �c F� <br /> Final Inspection By Date .:3 ZUZ 0 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS M -u Wx divi qq u fou ctd��i5 Zg70$ d- Y2 r?oQ <br /> FN S rt-ca/0'&Vl�- 9 kA.,ti NC4 <br /> PE SC Received a Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> LI-ZZ Z S'l to741 V, <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114118 <br />