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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS p CITy21P/ 4�f� Z, <br /> CROSS STREET�J dfii Ice APN. PARCEL SIZE O <br /> �_� � y� <br /> OWNER NAME �� /IZZI[!i�['cf.J -� E�L+mar /1 1 F i P 1' PHONE <br /> OWNER ADDRESS (9700 1e/ J a//s CITY/STATE/ZP &1-1 <br /> CONTRACTOR PHONE 7JL <br /> -5—OZ/7l <br /> CONTRACTOR ADDRESS _� 6/; � JJ��/G f�� CITY/STATERIP 511F�w�J <br /> LICENSE YC.C--42 11C36 OTHER NUMBER EXPIRATION DATE OS/7/ <br /> WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# S LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM _ DESTRUCTION <br /> INSTALLATION WILL SERVE: tL RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: Ji NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG ' <br /> CAPACITY 'e(n gal #OF COMPARTMENTS_ <br /> ❑ GREASE TRAP TYPE/MFG y CAPACITY gal #OF COMPARTMENTS <br /> / <br /> DISTANCE TO NEAREST: WELL & It FOUNDATION N PROPERTY LINE 570 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT 0 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES .. LEACHING CHAMBERS #OF LINES Z LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL f I�R FOUNDATION_A ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH it LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLIt FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it <br /> ❑ SUMPS WIDTH it LENGTH ft DEPTH It <br /> DISTANCE To NEAREST WELL ft FOUNDATION it PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH It DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER 7- WIDTH %�11 It DEPTH ':� ft <br /> DISTANCE To NEAREST WELL 7[A R FOUNDATION L� It PROPERTY LINE y(J R <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 /> M 49 HO 96Aj2VAAjQgE O CTI LE -7 <br /> SIGNED TITLE DATE b O <br /> \� y4f, � <br /> 00 c��VFt� <br /> T <br /> �0 0 6 2070 <br /> N�IRp USN C <br /> Ty O�pq�ou'v�Y <br /> T <br /> DEPARTM TONLY <br /> Application Acceptedn" — Date 0 d �a Area L Cf cl Employee ID#_..-bA <br /> Final Inspection By •Date 0 12=gno ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PIVSump Soil Character: <br /> COMMENTS M P vJ < P Q. ��Pr L <br /> PE SC Received (Check#/h Amount Date PermlV Invoice# Permit ID/ <br /> Code INFO Remitted Service R oast# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/16 <br />