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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jor a ADDRESS OvaC-(.' - rlr..nlP I C Lh7 S 2 O S -- <br /> c <br /> CROSS STREET Od I/S'�t \ APTN�'143 ,00,;-0 PARCEL <br /> p/ �[ ' /l .'SI`G�L�-�•' ::`;�G�ITYLIS !-. . PARCEL�SIZE <br /> OWNER NAME PHONE .70V <br /> (w,--A <br /> S �F'S� mo <br /> OWNER ADDRESS <br /> — TATE/ZIP 7 <br /> i. <br /> CONTRACTOR`-•c+a 1 TAI�t,S� rI`I G '�G/[��-!'ID PHONE /7�/ �� �/•1 -(Jf/�'-��../ <br /> CONTRACTOR ADDRESS ��Q � - '� ✓`���I CITY/STATE21P Qnbc�- b,.- <br /> LICENSE ,C42 QC-36 OTHER NUMBER 7 3 j p EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: Lj NEW INSTALLATION REPAtR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> C REPLACEMENT 71 OUT-OF-SERVICE SEPTIC SYSTEM LI DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE OMMERCIAL ❑ OTHER G <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: Cr) C) <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> 1� GREASE TRAP TYPE/MFG 60"A , � CAPACITY �b'O O gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL N(A_ it FOUNDATION I ft PROPERTY LINE 5 1l <br /> VLIFT STATION SIZE �PE OF PUMP 60 PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> y� <br /> LEACH LINES 14 LEACHING CHAMBERS�1�,f'-I #OF LINES 2- LENGTH OF LINES l 17 b ft <br /> DISTANCE TO NEAREST WELL rte'A ft FOUNDATION I n it PROPERTY LINE ft e <br /> ❑ FILTER BED WIDTH It LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE <br /> ❑ MOUNDED WIDTH it LENGTH it DEPTH <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY UNE ft (+ <br /> ❑ SUMPS WIDTH It LENGTH ft DEPTH it 1` <br /> DISTANCE TO NEAREST WELL It FOUNDATION R PROPERTY LINE R it <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH it DEPTH <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE <br /> SEEPAGE PRS NUMBER 11 - R DEPTH �-� _ E ft <br /> _JKANCE TO NEAREST ft FOUNDATION _ft PROPERTY LINE .�- ft <br /> 1 HEREBY CERTIFY AT I HA PREPARE PLICATI��AN HEWORKWILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES'T WS ANDD REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIN! UM H V E /RED FOR INSPECT/ONS-PLEASE CALL 209 953-769��7 <br /> SIGNED TITLE O DATE d3 <br /> JzA <br /> '41- - gu <br /> ' p <br /> -- - -- - <br /> ZZ V <br /> AE <br /> 1 - D p H c .' <br /> LZ <br /> DEPARTMENT USE ONL Y -Zr <br /> Application Acce to Area Employee ID# h l <br /> Final Inspectiony ❑ SPECIAL PERMIT-Approved by -'-�`, <br /> Character of Soli to D IIT of 3 Ft: Pit/jump Soil Character: x <br /> COMMENTS S _ <br /> Z/ <br /> �.�9«'���/itTc ZI/L=,S�-�7cc ssrslc-n .DC7 cam•/.v� - �!g < �l __ - <br /> PE SC Received Check# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Request# <br /> 2 < 2 <br /> C1?tti�7i.��j i�L(cyJ.S�F-7u;s PLIr�� CF•�Ln G�4t°,�Ciscy,p-�-,u,�7«.,1Z. <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 9121110 <br /> �L <br />