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i <br /> ONSITI : 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 INSPECTIONSI EXPIRES 1 YEAR FROM DATE ISSUED <br /> f <br /> JOB ADDRESS b 1 CITY/ZIP r f e 0 V CC1 r/"pgsa 3") <br /> CROSS STREET 1�► / pD r } APN 33 a o 1 PARCEL SIZE , y <br /> 0 <br /> //'' <br /> U' <br /> 0 <br /> OWNER NAME G I, I I ls' k h c hU►ti� PHONE <br /> [ <br /> OWNERADDRESS CITY/STATE/ZIP I ✓err <br /> �'r ��"•� 1S(l� 'R 1 <br /> CONTRACTOR � �J �iPSLI plr CcIJY�S1J PHONE ,/L <br /> CONTRACTOR ADDRESS UX I S w CITY/STATE/ZIP �/✓r]) <br /> LICENSE ❑nC-42 011C-36 OTHER NUMBER EXPIRATION DATE 3� / <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> Ii REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM P� DESTRUCTION fZ^{nK <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 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 i_' LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL 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 ff 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 HER BY CERT Y TH AVE PREPARED THIS APPLICAT N AND THE ORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS RULES AN EGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINI 48 HOU ADVANCE. ICE RE IRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNS TITL - DATE 3 vadU <br /> �t <br /> ZIi <br /> A <br /> J AC UIAI <br /> r <br /> DEPARTMENT U E ONLY q �V <br /> Application Accepted Ely ��� Date i► 3 df���'b^ Area 1 / Employee ID# <br /> y V <br /> Final Inspection By !(!c 's!%4c Date �.i/w C SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS 4 t of w 10 I vL tC <br /> ����P ��,,...t. c off-, ✓�rr�+z Ill h eon✓� r��-c h r ,.�e l/�, (��-c.6�� f� <br /> K e( �c 5tv'o d aCc,Yi e .xz (rte . <br /> PE SC Received Che #/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> 9d a v7s- <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/16 <br />