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y 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 <br /> / _-. - ------_ _ ._' C Y/ZIP _ -------_- O6 _ nI0-�n <br /> CROSSSTREET APN0��/O1� Dr <br /> QCPARCEL SIZE <br /> a <br /> OWNER NAME NAME B�.iCP.r�( 2pq) 68 -1 z <br /> PHON <br /> OWNERADDRESS __ _ _CITY/STATEMIP <br /> CONTRACTOR OYY.LILS! _ - PHONE... . <br /> I CONTRACTOR ADDRESS _ _ - CITY/STATEMIP <br /> jLICENSE C-42 C•36 OTHER NUMBER -------_- EXPIRATION DATE <br /> WATER TABLE DEPTH:_ ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> PERC TEST # __. BUILDING PERMIT Al ' _ _ LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION Ne REPAIR/ADDITION ENGINEER DESIGNED[ALTERNATIVE ` <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: VRESIDENcE COMMERCIAL OTHER -_-_ <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: - - NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE,MFG _ CAPACITY ___ __- gal #OF COMPARTKIENTSL <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OFC0k1PARTMENTS.__ <br /> DISTANCE TO NEAREST: WELL It FOUNDATION ,_ .. it PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) (' <br /> V/LEACH LINES LEACHING CHAMBERS _ _ - #OF LINES_A— LENGTH OF LINES_ O" ft ' <br /> DISTANCE TO NEAREST WELL _It FOUNDATION, ft PROPERTY LINE It <br /> ❑ FILTER BED WIDTH ---- It LENGTH--_--.- -- —�.. ft DEPTH---___ <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE <br /> ❑ MOUNDED WIDTH -it LENGTH _ft DEPTH h <br /> DISTANCE To NEAREST WELL- _ _— it FOUNDATION -_ _- -_- ft PROPERTY LINE_- <br /> ❑ SUMPS WIDTH _- ._ _. it LENGTH - - _ - -- It DEPTH _ _ it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH _--.-ft LENGTH -_ _.____ ____ft DEPTH _ It <br /> DISTANCE TO NEAREST WELL-__...,... . - ft FOUNDATION __- __. it PROPERTYLINE ,.— ._ _ it <br /> ❑ SEEPAGE PITS NuMBER_ __ __.__ WIDTN___ ______- --ft DEPTH_._ -_ ft <br /> DISTANCE TO NEAREST WELL_-___ -- ft FOUNDATION __ft PROPERTY LINE -__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 LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUIW48HOUR44DVAIVCE OWE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-76970 <br /> SIGNED TITLE �I�` DATE <br /> I <br /> w or <br /> - y p8 ao <br /> / QVIN <br /> F qR�PNTY <br /> AtNT <br /> / DEPARTMENT O (� Employee ID#_ bA/� <br /> (,� _ Area ��/ -__ <br /> Application Accepted By � Date S �D <br /> Final Inspection By ___ Date-- 2o" SPECIAL PERMIT-Approved by <br /> Character of Soilto Depth of 3 Ft- -_ P ump Sojl Character: ._.-___ <br /> COMMENTS-F-41 leC4 1+4 P.. PA)— S'f�SYS on I&Yj s jirt c, );> . T-2cr <br /> PE SC Received Check#/ Amount Permit/ —--� <br /> Code INFO Cash Remitted Date Servi nest# Invoice# Permit ION <br /> dal a fIs V ,5 300 <br /> I <br /> 107 74q F� <br /> Y'"I" d1Y�i��ti�9+� ah'cif:Ti#'tEAh"fl�'�T�Fh'1�'•_�14T <br />