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I <br /> #' .0 -.5 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3424 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEARFR M DATE ISSUED <br /> JOB ADDRESS U059 CITYIZIP <br /> rr r� w <br /> CROSS STREET_ [y1 Il APN (_` PARCEL SIZE D <br /> d <br /> OWNER NAME--- y� r sem' I�e„( {f,VZ _ PHONE <br /> OWNER ADDRESS C-IM ALI-'- CITY/STATE21P <br /> CONTRACTOR__ � �L/_� _ L�,r,r {' PHONE <br /> CONTRACTOR ADDRESS CITY/STATEIZIP 0_-r d <br /> LICENSE [�C-42 QC-36 OTHER 14 NUMBER EXPIRATION DATE _atA <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: L].�ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> O SEPTIC TANK TYPEJMFG CAPACITY gal #OF COMPARTMENTS <br /> D GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> - DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> D LIFT STATION SIZE TYPE OF PUMP _.-_0 PKG TX PLANT O SAND OIL SEPARATOR(EN SYSTEM) <br /> �s N <br /> EACH LINES W LEACHING CHAMBERS ail #OF LINES LENGTH OFES L) ft <br /> DISTANCE TO NEAREST W L FOUNDATION r ft PROPER LINE ft <br /> O FILTER BED WIDTH ft ft DEPTH ft 4- <br /> DISTANCE <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft C <br /> 0 MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> 71 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)953-7697 <br /> SIGNED TITLE 6exd sbrcc4u I= DATE 77 Cr f6 <br /> fr <br /> =NVIRONNi <br /> I <br /> 3 <br /> I <br /> E A <br /> HE AIJH ME <br /> .I <br /> DEPARTMENT SE NLY <br /> Application Accepted By _ - - to '- -Area-_6 ' �.r--Employee'ID#'— D <br /> Final Inspection By Date 3 SPECIAL PERMIT-Approved by r <br /> Character of Soil to D pth t: Pi ump Soil <br /> of 3 FCharacter: <br /> COM NTS /2 L rI <br /> Csr� <br /> PE Sc Receivedec Amount Date Perm Invoice# Permit ID# <br /> Code INFO B ash Remitted Servi a uest# <br /> 2 o U D•$ z 0 rem <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 6/26109 <br />