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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT 1668 E. HAZELTON AVENUE -STOCKTON CA 65205-(209) 468.3420 <br />CALL 209 953-7697 FOR INSPECTIONS <br />J( ,r" i� EXPIRES 7 YEAR FROM DATE ISSUED <br />Joe ADDRESS 4i/%1 I `L' k t '1'�I,w. �!p CITvrZIP�t,' G,11• <br />CROSS STREET _ jf Dj�ee <br />1_" APN Q— .� On -!`f <br />OWNER NAME 4: 1MYtr �li l� }7 <br />�[;! PARCEL SRE <br />( � <br />OWNER ADDRESS 117Ck6 CJ:sJ N_ PHONEL-0,56��aLIU <br />Cm/STATE/ZIP <br />coNrRAcroR_ ,rye t� h�cicti ,-, <br />PHONE <br />CONTRACTOR ADDRESS Ar ,� f • (E$'p <br />CIN/STATE/ZIP 1je-: A4ejj1(4EL�-i <br />LICENSE ❑DC -42 11pC-36 OTHER_ �- <br />NUMBERf�tti'.�5q EXPIRATION DATE_Aj2..j,Z. <br />WATER TABLE DEPTH: _�.,� O ft GEOGRAPHICAL INFORMATION: Coordinates X <br />0 PERC TEST #' Y <br />T <br />BUILDING PERMIT #, LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION <br />^ REPLACEMENT_ ...-'I II rNGINEER UE <br />V OUT -OF -SERVICE SEPTIC SYSTEM D DESTRUCTION <br />INSTALLATION WILL SERVE: "SIDENCE ❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: <br />Ni M <br />SEPTIC TANK TYPE/MFG CAPACITYt �. ?1-�j BER OF EMPLOTEES: <br />❑ GREASETRAP TYPE/MFG gal #OF COMPARTMENTS D, <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL (_ ft FOUNDATION, <br />❑ LIFTSTATION SIZE � ft PROPERTY LINE r�s-7 ft <br />TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />Ur LEACH LINES ❑ LEACHING CHAMBERS # OF LINES _ LENGTH OF LINES 01 <br />n <br />DISTANCE TO NEAREST WELL I Cin' ft FOUNDATION�t ft PROPERTY LINE <br />(3 FILTER BED WIDTH ft LENGTH it DEPTH <br />DISTANCE TO NEAREST WELL n <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br />DISTANCE TO NEAREST WELLft <br />ft FOUNDATION PROPERTY LINE ft ft <br />❑ SUMPS WIDTH ft LENGTH ft DEPTH <br />DISTANCE TO NEAREST WELLft <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH it LENGTH It DEPTH <br />DISTANCE TO NEAREST WELLft <br />ft FOUNDATION ft PROPERTY LINE it <br />SEEPAGE PITS NUMBER WIDTH 6 j tl ft DEPTH _; ,S 1 <br />DISTANCE TO NEAREST WELL + ft <br />�S;] tf FOUNDATION A} ft PROPERTY LINE_�S' it <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 8 UR DANCE TIGE E U RED F INSPEC I S - PLEASE CALL 2 953-7697 <br />SIGNED TITLE_ "r L),X /64Zf-o (' DATE I1 10 <br />I mCry 1 NSE ONL <br />Application Accepted y G / L �— Date /r ,?) Area C� % Employee ID# <br />Final Inspection By sae°. Date 3 �D7{ ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 FN pit/Sump Soil Character: <br />COMMENTS St?LV I?[•� C FR % 1 P 1 N-,, vUS lls vJ 1 it, <br />l sPi��ic�E_< �t ` � fl rPr��r s. <br />PE <br />SC Received <br />Check# <br />Amount <br />Permit] <br />rmrm <br />INFO B <br />Cash <br />Remitted Date <br />Service uest # Invoice # Permit ID# <br />42.01 <br />4/14118 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />y <br />n <br />d <br />0 <br />