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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET - STOCKTON CA 95202 • (209) 4683420 <br />AVON-KEFUNDABLLE VERMI 4.;fkLL LUV) 1t03-1Utlf FOR INSPECTIONS tXPIRE5 1 YEAR FROM DATE ISSUE! <br />JOB ADDRESS P/_3 Q Sot I,LM� CIryrhP 61411 �,,- �4 <br />^ <br />CROSS STREET I� w r Je % APN 6 a 57 1700 00 � / f�PARCEL SIZE <br />OWNERNAME/�yt[/�[� PHONE Qr <br />OWNER ADDRESS CITYISTATErLP 15'atrx a.., <br />CONTRACTOR efs,14-d U,4-,��-3J/Z-5-PHONE f4 i - Sda % <br />CONTRACTOR ADDRESS 17000 CITYISTATEIZIP C.vlfr <br />LICENSE )IC -42 (,IC36 OTHER NUMBER ;f 1s/C-EAPIRATIONDATE 07-11'/U <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # <br />BUILDING PERMIT # <br />DISTANCE TO NEAREST <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />L NEW INSTALLATION X <br />REPAIRIADDRION <br />C ENGINEER DESIGNED IALTERNATrVE <br />DEPTH k <br />U REPLACEMENT LJ <br />OUT -OF -SERVICE SEPTIC <br />SYSTEM G DESTRUCTION <br />INSTALLATION WILL SERVE: JC REsIDENcE <br />COMMERCIAL <br />n OTHER <br />ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />it PROPERTY LINE ft <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />ft LENGTH ft <br />❑ SEPTIC TANK <br />TYPE/MFG T-V�S-A:'L <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPEiMFG <br />CAPACITY <br />gal #OF COMPARTMENTS <br />DEPTH it <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />it PROPERTY LINE R <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />IA LEACHING CHAMBERS # OF LINES �_ <br />A! <br />LENGTH OF LINES %O40 ft <br />DISTANCE TO NEAREST <br />WELL It FOUNDATION O f <br />ft PROPERTY LINE /547 �-ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH ft <br />DEPTH k <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />it PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH ft <br />DEPTH it <br />DISTANCE TO NEAREST <br />WELL it FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH It <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />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 />MINIIII <br />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED <br />0 <br />TITLE ��� <br />DATE Z- ZZ- I Q <br />Application AccepN <br />Final Inspection 4 <br />Character of Soil to <br />COMMENTS G <br />of 3. Ft: <br />r <br />DEPARTMENT USE 91NLY <br />Date 1� O Area Employee ID <br />Date L l0 -- SPECIAL PERMIT -Approved by <br />PWSump Soil Character: <br />y 42-01_ ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />8120109 <br />D <br />0 <br />m <br />Lam: <br />A <br />4 <br />PE SC Received Chec <br />Amount toP°�lI Invoice A Permit IDA <br />Code INFO B <br />Remitted Service R zest # <br />0d2 I <br />CJC O <br />y 42-01_ ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />8120109 <br />D <br />0 <br />m <br />Lam: <br />A <br />4 <br />