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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 <br /> 1 PERMIT CALL 209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS `�-\ ` 1�Ln la �-6 CITY/ZIP 1` \r(1 p v <br /> =a <br /> CROSS STREET t� APN ' \` - 1(I ~ V a PARCEL SIZE p <br /> OWNER NAME 'V O Y(�1. �V� QKYV�V l ` ! \Y��e�J�1 ` PHONE <br /> OWNER ADDRESS Vy� ,r \V Y�G 1� "v� CITY/STATE/ZIP <br /> I <br /> CONTRACTOR St�\I�I, � 4"r PHONE <br /> CONTRACTOR ADDRESS \� L ,1\ ' CITY/STATE/ZIP <br /> LICENSE ❑11C-42 ❑❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: Io^'�a ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 0 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT Ci OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: (( NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY ICY) gal #OF COMPARTMENTS v <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ���^ ft FOUNDATION ' ft PROPERTY LINE ' --3' ft <br /> LIFT STATION SIZE i/� h p TYPE OF PUMPG�Zdf ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS It\�trv,'�f #OF LINES LENGTH OF LINES C ft <br /> FDANCE <br /> IANCEToNEAREST WELL tift FOUNDATION (9O' ft PROPERTY LINE ✓O ft <br /> ElFILTER BED TH ft LENGTH ft DEPTH ft <br /> 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 /> MINIMUM HOUR LANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLEd� DATE�� <br /> HE 1117% <br /> C U <br /> 1,W IR N E <br /> H <br /> DEPARTMENT, UE ONLY <br /> Application Accepted By Date �O a8�� Area - I Employee ID# <br /> Final Inspection By R, Date III W ElSPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS n 4. IE 140 W ,I S W4hlP (7 Ped 02e( / <br /> 3 <br /> I0I20Z0, <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO y C h Remitted Service Request# <br /> 13 117 +s 9L <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14118 <br />