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y • <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 96205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)_9 G .V <br /> 53-7697FORWPEcvibn EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I�"� �7 Q ��C12,�a- Y1CJ e-A r�CITYIZIP� �1 � l s- 7�+' <br /> CROSS STREET Jyiy.. 111 kr APN L1 J ( L+ 6�PARCEL 512E t J > <br /> � a <br /> � a <br /> OWNER NAME_ j^'Q ��� PHONE <br /> <�j'.Ot a <br /> OWNER ADDRESS l��G�//J � ' - / lVO3 CITY/STATE/ZIP _l •l' �/fj �y� <br /> CONTRACTOR G Kz/MwL YX'J�w.' �c'/ PHONE �G 51 w576 7-2 <br /> CONTRACTOR ADDRESS �.t%lTC.c. 7i9i� J:�,+C CITY/STATE/ZIP <br /> LICENSE q�t-42 ❑LIC-36 OTHER NUMBER iJS*tl-5" EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> r❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION D REPAIR/ADDITION D ENGINEER DESIGNED(ALTERNATIVE <br /> 1.1 REPLACEMENT D OUT-OF-SERVICE SEPTIC SYSTEM Cl DESTRUCTION <br /> INSTALLATION WILL SERVE: /o RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: :9 NUMBER OF EMPLOYEES: <br /> R- SEPTIC TANK TYPE/MFG f''+L CAPACITY ,��JD gal #OF COMPARTMENTS_ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY 921 #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION fCJ It PROPERTY LINE SCJ _It <br /> Q LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> Q. LEACH LINES El LEACHING CHAMBERS #OF LINES_-3_ LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL f 5'0 it FOUNDATION JAS ft PROPERTY LINE 5JL1 it <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE it <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> 0 DISPOSAL PONDS WIDTH ft LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> SEEPAGE PITS NUMBER _J WIDTH y,V" ft DEPTHS ft <br /> DISTANCE TO NEAREST WELL D — R FOUNDATION d 5- it PROPERTY LINE ft <br /> 1 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 /> tin <br /> ADVANCE NOLICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-769 <br /> SIGNED -- TITLE C.r./fJr....b+G. DATE l <br /> J <br /> Nr <br /> D <br /> m <br /> F <br /> �.- -DEPARTMENT USE QNLy <br /> Application Accepted y _ Date Area Employee ID# �-- <br /> 17 <br /> Final Inspection By Oate ❑ SPEC( L PERMIT-Approved by <br /> Character of Soil to of 3 9- PiUSump Soil Character: <br /> COMMENTS <br /> PE SC Received 4nigwy <br /> Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114116 <br />