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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 CALL209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �7 p q y <br /> JOB ADDRESS ` '�� /" CITY/ZIP 00 AV <br /> CROSS STREET Mom APNZ's . I PARCEL SIZE / 0 @p <br /> OWNER NAME `L�+(I 1 �illt�.�- �+LL /�1nI�1 _- APHONE Fri <br /> OWNER ADDRESS 2 C)I` 1441 ` i%'- I�' y- CITY/STATE/ZIP �a PQ' <br /> CONTRACTOR —0101iif& Saoo t 0 �(✓& PHONE `l •J .r �,,Y/�S 3 {�'+-� <br /> CONTRACTOR ADDRESS / /Vy y�:C/e NL/.,f--_j �d)�' _.CITY/STATE21P � <br /> LICENSE 11, C-42 [If C-36 OTHER NUMBER /153 EXPIRATION DATE r r oeV� / <br /> 1 <br /> WATER TABLE DEPTH: 1 S it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# __.. LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM .. DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:-- NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPEIMFG CAPACITY (gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG _ CAPACITY _ gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL It FOUNDATION it PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES _I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> Y <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE-- ft <br /> Iff FILTER BED WIDTH IC) ft LENGTH d r it DEPTH N 7a it <br /> DISTANCE TO NEAREST WELL kob , it FOUNDATION &0 it PROPERTY LINE_ 10, it <br /> ❑ MOUNDED WIDTH it LENGTH _ it DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE_ it <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH _ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE_ ft <br /> ❑ DISPOSALPONDS WIDTH It LENGTH - ft DEPTH , It <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE it <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL _ it 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 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE 9:�( DATE_ ��� 6 <br /> L <br /> A J A U O N <br /> DEPARTMENTU EONLY Ta <br /> ptl��qqH�EALTH DEPARTlI �- <br /> Application Accepted B _. l/ Area Employee ID# �— <br /> Finai inspec:ioD By _ Dote 3IN_FQ, ..,.--.__ ❑ SPECIAL <br /> PERMIT-Approved 6v <br /> Character of Soil to D th of 3 t: 't/Sump Soil Character: <br /> CO ENTS <br /> 011 <br /> -- <br /> PE SC Received Check#/ Amount Date PermiU Invoice# Permit lD# <br /> Code INFO Bv Cash Remitted Service Request# <br /> zlu �r > 13 2a�- 3-y-Ib 52ou'r�13G <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />