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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 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS �! V /' CITY/ZIP , <br /> CROSS STREET ('��� ��( A 14, APN 0 9115 D 1379 "1 <br /> PARCEL SIZE � =� <br /> OWNER NAME /�/ !/VY�I(� ����r��ni�), Enm� PHONE - y <br /> OWNER ADDRESS Cl-qf4A j CITY/STATE/ZIP <br /> CONTRACTOR /22 d4id / /11,sT� Q 6;(& - PHONE �J 16y�1y <br /> CONTRACTOR ADDRESS ���1�2 � ' Z CITY/STATE/ZIP <br /> LICENSE :11-IC-42 ❑11C-36 OTHER NUMBER goal <br /> EXPIRATION DATE <br /> WATER TABLE DEPTH: / ^�y� ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: J NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENTL^ OUT-OF-SERVICE SEPTIC SYSTEM X DESTRUCTION i4,11 k <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL <br /> ❑ OTHER <br /> NUMBER OF LIVING UNITS: ,O NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY t <br /> 11-4z__ gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFGCAPACITY ) gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL_ e///,,� ft FOUNDATION J 7`- ft PROPERTY LINE S j� ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES i . LEACHING CHAMBERS / #OF LINES / 6W LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL�A"IZ' ft FOUNDATION /� ft PROPERTY LINE 5- L 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 NEA ST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> � � 7 <br /> &CSEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL_,f�� ft FOUNDATION �U�7 ft PROPERTY LINE r -7_ 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 /> MINI 48 HOUR 4DVAOE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 20 953-7697 <br /> SIGNED TITLE C__ DATE <br /> B IN <br /> FrA <br /> T <br /> DEPARTMENT USE ONLY i 41418r <br /> L . <br /> Application Accepted By, �G Date � ow'0 Area Employee p yee ID# DA. <br /> Final Inspection By Date 2 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS 0P<16dire, sVsfer-- Addh% 167kik clod ex IMip <br /> o te,l -(• a-' o..�^� `V1es art/ _ 1/9' plfS. ,-i2lgi <br /> Q'✓I b u C ,o ✓L V-094 CL /moi • ' /lo <br /> PE SC Received Check#/ Amount Permit/Code INFO B C Remitted Date Service Request# Invoice# Permit ID# <br /> Halo 11s- ('� $3c�0 Lo �S ;- <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/16 <br />