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' if ASIYE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAOJIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE,,//PERMIT CALL 209 95 -7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Com' <br /> JOB ADDRESS Q� �U _ CITYR^IP <br /> CT U <br /> CROSS STREETAPN 131 10%a PARCEL SIZE q. 0� <br /> OWNER NAME � ' � U yy /Cr- L" / P PHONE r <br /> OWNER ADDRESS P CITYISTATE/ZIP ke+I11V �S l <br /> CONTRACTOR _ I' Vr4, 0 oc PHONE //J <br /> CONTRACTOR ADDRESS -917` ,—[/l� �'' CITY/STATE/ZIP JT�4163 L <br /> LICENSE I lC-42 l C-36 OTHER NUMBER V/ EXPIRATION DATE_ <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> F; PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> I <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE Ll COMMERCIAL L1 OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: S 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 It <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 /> c <br /> DISTANCE TO NEAREST WELL /(�D ft FOUNDATION 36ft PROPERTY LINE_ /"00/ 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 _ WIDTHS ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ' 1� ft FOUNDATION ft PROPERTY LINE _�"�✓ Z 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697'7 <br /> SIGNED _ TITLE C�11�'� DATE�I._ <br /> _ L <br /> T <br /> nFPA' .RT.^.4Ef`IT I)c n+,, y <br /> Application Accepted By ', 'G� _ - Date o,zDdj Area _[� Employee ID#_._ <br /> Final Inspection By Date (o Ll SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: _ Pit/LSumprSoil Character: <br /> COMMENTS Fn I h/!e bf >HPS )e•r 1 �T 0- _ 50; 1 4n w_ t <br /> _ �!�- GV+�- 1�I.2Gy � � ate✓ ���-- <br /> p-✓( <br /> PE SC Received Chec Amount Permit/Code jIN1FO B ash Remitted Date Service Request# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />