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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E,HAZELTON AVENUE-S rOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOR ADDRESS+, �),v��\ �1 �f r5 r`: itJ�( _ ITY/zlr_"•'X141.1C f� 3 3 <br /> CROSS STREET Q�C/r�yV^— _ A)PN—_. _.ZO -� PARCEL SIZE O�GC.ft^ C <br /> OWNER NAME_ L W N J I ARh (il-r1.1�� PHONE <br /> OWNER ADDRESS � 10,0.1 D�, _CITY/STATE/ZIP � ! �+•G { 7 <br /> CONTRACTOR �--- <br /> CONTRACTOR ADDRESS _ O _Ire COU CITYJSTATE(ZIP <br /> LICENSE C-42 C r/.� <br /> 4 4c-3s OTHER NUMBER JL'O� EXPIRATION DATE `L.J 1 ^— ( __ <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X_ Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: 'I NEW INSTALLATION REPAIRIADDITION .i ENGINEER DESIGNED/ALTERNATIVE <br /> tl REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: 79--Res16ENCE COMMERCIAL F) OTHER <br /> NUMBER OF LIVING UNITS: _ NUMBER OF BEDROOMS: NUMBEn OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG C-Y +E— CAPACITY � gal #OF COMPARTMENTS _ _ <br /> ❑ GREASE TRAP TYPEJMFG ,�..----•• CAPACITY -_ _— gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL .15'n'n It FOUNDATION 11 PROPFRTY LINE TO ft <br /> O LIFT STATION SIZE TYPE OF PUMP _❑ PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> O LEACH LINES -� LEACHING CHAMBERS HOF LINES LENGTI I OF LINrs it <br /> DISTANCE TO NEAREST WELL It FOUNDATION_t! PHOPE111Y LINE It <br /> ❑ FILTER BED WIDTH it LENGTH it DEPTH _It <br /> DISTANCE TO NEAREST WELL it FOUNDATION It PROPERTY LINE it <br /> ❑ MOUNDED WIDTH it LENGTH it DEPTH PQVne. it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINIRj=r-_-r-. fl <br /> ❑ SUMPS WIDTH It LENGTH it DEPTH �! r n it <br /> DISTANCE TO NEAREST WELL it FOUNDATION if PROPF RTY LIN-JUL I 9 Enf _It <br /> ❑ DISPOSAL PONDS WIDTH it LENGTH If DEPTH SAN�pI�A it <br /> DISTANCE TO NEAREST WELL 1t FOUNDATION 11 PROPE T jrvr VfRnn^EL C�It <br /> C] SEEPAGE PITS NUMBER WIDTH -__ ft DEPTH � A1711 DLPAUT"ABYT it <br /> DISTANCE To NEAREST WELL It FOUNDATION It 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 /> INI UM HO VAN N E REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED _ _ TITLE — DATE <br /> III <br /> - I — <br /> T. <br /> E -- - - <br /> i <br /> I <br /> I <br /> I <br /> O-E-P A R-TALg4 Tfj R F,C N L Y <br /> Application Accepted B Date 19 Area _pQ9CmployeaTD# ✓rd p/JLwry <br /> Final Inspection By Data F] SPECIAL PERMIT-Approved by <br /> Character of Soil to epth of 3 Ft: Pit/Sump Sol[Character: <br /> COMMENTSJ. <br /> ad ✓Co f �erlaGt.y�� tr l^ kL.� �"�^�t <br /> E SC Received Chec Amount Date Perml Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4124!12 <br />