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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 O�/ CITY/ZIP IVo94 c-,-q 'LEI v <br /> -j <br /> CROSS STREET Saa4LW401APN 910 PARCEL SIZE �V y <br /> 0 <br /> / j p 0 <br /> OWNER NAME �(v^O� PHONE.� 1 6 tl,—, /6�16 M <br /> OWNER ADDRESS 7(J '96' C/D V CITY/STATE/ZIP Z/"L'-LC/ <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ -C-42 1117C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: Ll NEW INSTALLATION I` REPAIRIADDITION I ENGINEER DESIGNED/ LTERNA IVE <br /> F] REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 7—ez _ CAPACITY 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 / #OF LINES 1C LENGTH OF LINES O O ft <br /> DISTANCE TO NEAREST WELL � G 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 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 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 /> MINIM!JM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNE TITLE 4!1 &,,-7��� DATE <br /> Lj-E /A C <br /> +H y N <br /> T <br /> PARTMENT USE QNLY /^ <br /> Application Accepted B Date z Area —� Employee ID# <br /> Final Inspection By Date C SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept 3 Ft: U V Pi Sump Soil Character: <br /> COMMENTS`F c �uru� Inn�SS'oh (' ✓y. <br /> A- box av,& becSxnrirA ol- \ecxa% Uy-e5. <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By ash Remitted Service Request# <br /> �F 5 3 0D 2 I I S 3 <br /> ` D0 /2� 1 <br /> `� D C �r EO{ CpOI{ 1 P 0 <br /> 42-01 � <br /> ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> A"F- 6-tmo4/14/1 t � mor <br /> cI/Me <br /> {-;w� <br />