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42-01 <br />4114118 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />0%4144107 , <br />6,t,f4-44/v <br />, 4)14707;14 73.- 47. <br />DEPARTMENT USE ONLY <br />Application Accepted By LZ.-- Date /DP Area -iJ C(ti <br />Final Inspection By Date <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS <br />3 SPECIAL PERMIT - Approved by <br />itump Soil Character: <br />Employee ID# As <br />PE <br />Code <br />SC <br />INFO <br />Received l=liC Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Permit ID# <br />9 (3dd 5,13 <br />016, <br />1 6(71 4 ).f: 22_ 21 G MlYI L-1 a ;; <br />'1/411 <br />LI Li <br />1 ti•J 11 v) • <br />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 I 5-01 0 t.). G-LAS5C-ocie- P-1;) • crryaip L_Dt? 1 9 3 -.'-f <br />CROSS STREET <br /> tj'IN . 12- APN kOC) D ti PARCEL SIZE 4.0-444 AT • <br />OWNER NAME 'VC ig-tv‘11.1av 5 P-s1 1304ker do vi J SJ ot- <br />PHONE (XVI.- " 4t. I g <br />OWNER ADDRESS CV .1 0 S- 1.4 • CI- 1? 0-P-Nv <br />crryisTATE/zip 5-ro ck---rot-J c" 15- 2-01 <br />CONTRACTOR LA e- pips G-e D elQ i IRA" NnevIkti•JT" <br />PHONE GP 03 1 C <br />CONTRACTOR ADDRESS ADDRESS 44 01 in) • 0 Ok cirdsTATErzip L 01, c-A <br />LICENSE I C-42 1 C-36 OTHER C (7- NUMBER 2-I C- I <br /> <br />EXPIRATION DATE -3 0 -2;2 <br /> <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> <br />PERC TEST # <br /> <br />BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION <br />REPLACEMENT <br />REPAIR/ADDITION <br />OUT-OF-SERVICE SEPTIC SYSTEM <br />ENGINEER DESIGNED /ALTERNATIVE <br />DESTRUCTION <br /> <br />INSTALLATION WILL SERVE: E. RESIDENCE Ei COMMERCIAL <br /> <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />OTHER <br />NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />0 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 0 SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />0 # OF LINES LEACH LINES LEACHING CHAMBERS 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 />0 SUMPS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />0 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />0 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 />MINIMU 8 HOURANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br />SIGNED TrrLE Pe--0-, • vvk & DATE 2- -7-7- 2- 1 :SS311UUV 31Is