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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 -9-I, 0 1 O N Taj IAS S CITY/ZIP <br /> fj r <br /> CROSS STREET E LTA APN 0 30CPARCEL SIZE 10 C <br /> OWNER NAME I A' F; 5 1 i t N PHONE O-'K}0 q' <br /> OWNER ADDRESS <br /> ���//,�,/2��1�`` I 0 �0n a/ y_� `S i`"n CITY/STATE/ZIP Ln0 I CA/ -/�J� S 2— <br /> CONTRACTOR W,66C/" Cw J1 a�G`n b(I✓ PHONE-2-o2 -1711 X3`,02,( p <br /> CONTRACTOR ADDRESS 9-o - eo` g{'S n CITY/STATE/ZIP \J9u E I <br /> LICENSE ❑DC-42 ❑FJC-36 ``OTHER D NUMBER _l C)1�I EXPIRATION DATE 0 3 r ' X002 <br /> WATER TABLE DEPTH: +) ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# U LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION i] ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: E RESIDENCE COMMERCIAL ❑ OTHER p <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:,9 P/L; L) <br /> SEPTIC TANK TYPE/MFG L Ot-Ice-e -c. d' r CAPACITY �.2 b C7 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 3 #OF LINES_�� LENGTH OF LINES (40 ft <br /> DISTANCE TO NEAREST WELL 1 010 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 ftFOUNDATION ft PROPERTY LINE ft <br /> SUMPS 3 WIDTH Z ft LENGTH 14- ft DEPTH kc) ft <br /> DISTANCE TO NEAREST WELL�SQ ft FOUNDATION A-0 ft PROPERTY LINE IJAT <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH All n . ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> I HEREBY CERTIFY THAT I H VE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COU EA N dggp�N <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. /ICT//O �'►ENTqL <br /> 1L�JR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 EPgRTMEAIT <br /> SIGNED (IMTITLE (if L-Tf*M y DATE <br /> LLd <br /> l0 <br /> —1 LLI <br /> h` B <br /> a <br /> IO <br /> S <br /> 0 <br /> 5 q0V t <br /> •�c Ti <br /> �i <br /> I IA g <br /> D ARTMENT USE ONLY <br /> Application Accepteii By Date pJ0,�V Area yG Employee ID# Dfi _ <br /> Final Inspection B �- L✓ Date SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS T Pr ovw 4 (, S s iy <br /> ',.tSt-� C2� 1G. jp <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By_ Cash Remitted Service e t# <br /> Y)IF )sa � 3G,- T <br /> 42-012�� //�/G�0/� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4!14/18 `` G l <br />