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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 <br />REPLACEMENT <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 'N01 r I I F/A LAI <br />I <br />CITYIZIP l -u& , <br />(A q SZy D <br />CROSS STREET fit('rkryA !'j <br />NUMBER OF LIVING UNITS: <br />APN l)��I �VI{O 33U <br />PARCEL SIZE 7•��' A( <br />I <br />L <br />OWNERNAME tAl-l"Ll 1,4AI/ <br />NA,tc, <br />u.(-, <br />PHONE j l9 - 2 731 (�00 <br />OWNER ADDRESS I �'� 7V Iy G1F��rjy1 <br />GREASE TRAP TYPE/MFG <br />C111 AVZ r ! \ E ZSv CITY/STATE/ZIP <br />1rV�nC I I� L -2 (p I 7— <br />CONTRACTOR <br />DISTANCE TO NEAREST: WELL <br />PHONE <br />It PROPERTY LINE _ft <br />CONTRACTOR ADDRESS <br />LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ <br />CITY/STATE/ZIP <br />LICENSE Fl. C-42 C'i� C-36 OTHER <br />❑ SUMPS <br />NUMBER EXPIRATION DATE <br />ft <br />WATER TABLE DEPTH: <br />❑ PERC TEST # <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />BUILDING PERMIT# LAND USE APPLICATION # <br />❑ LEACH LINES <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />W,, DESTRUCTION �%N C - <br />INSTALL <br />ATION WILL SERVE: ❑ RESIDENCE <br />E' COMMERCIAL <br />❑ OTHER <br />ft FOUNDATION_ <br />NUMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ <br />SEPTICTANK TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />WIDTH <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />It PROPERTY LINE _ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LI LEACHING CHAMBERS <br />#OF LINES <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION_ <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION _ <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION_ <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION _ <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />LENGTH OF LINES ft <br />ft PROPERTY LINE It <br />ft DEPTH ft <br />ft PROPERTY LINE ft <br />ft DEPTH ft <br />ft PROPERTY LINE It <br />ft DEPTH ft <br />ft PROPERTY LINE ft <br />ft DEPTH ft <br />f: PROPERTY LINE ft <br />_ft DEPTH ft <br />(t 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953,r-7697 <br />SIGNED k- TITLE DATE Z!Ii'jZZ <br />DEPARTMENT E NY r^^ <br />Application Accepted By Date Z2 Area Employee ID# <br />Final Inspection By ' Date -Z Z Z ❑ SPECIAL PERMIT • Approved by <br />Character of Soil to Depth f 3 Ft: Pit/Sump Soil Character: <br />COMMENTS YfiGei-e 1L PxiJ�z.c� �ibe%�i t�iS' <br />PE SC Received Check#/ AmountPermit/ <br />Code INFO B Cash emitted ate( ervice Request # Invoice # Permit ID# <br />I <br />42-0' ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14)18 <br />