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<br /> ar-: 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 r CALL 209 953-7697FOR INSPECT70NS EXPIRES 1 YEAR FROM DATE ISSUED
<br /> JOB ADDRESS�[/.,}r6 I .SI C/ L�/C.[.tJ G/....................._._._CITY/ZIPil
<br /> .lC'.a rr�-5._.......... er',{. O
<br /> CROSS STREET "Ty� —" ,
<br /> __._.—_--------............._....._...._..___APN. � ". .(J _._.___..._.....................PARCEL SIZE...(, -c........ ..� v
<br /> OWNER NAME......Ll.,Cr �� � .`c/iC�1 5,14E eviL .................................PHONE......_._......_...__.._.....___..___..._.._.____...�____
<br /> OWNER ADDRESS ................. CRYJSTATEIZ4IP :_ ,.,,,_„_,,,,,,,,,,,,,,_„___,,,_ p••�.
<br /> CONTRACTOR e-e. !"/1/ _ t.O C.. PHONE
<br /> CONTRACTOR ADDRESS 'f/.6 O/S�/'`V Ui"C CRY/STATE/ZIP
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<br /> LICENSE i..ije.42 1.1.'C-36 OTHER. NUMBER 4/S-'r*yS--EXPIRATION DATE_
<br /> WATER TABLE DEPTHJ4-0 I Gd if GEOGRAPHICAL INFORMATION: Coordinates X_ Y_„___.,,__�„_
<br /> PERC TEST # BUILDING PERMIT If __,LAND USE APPLICATION#..._......_.___..__
<br /> TYPE OF WORK: g: NEW INSTALLATION REPAIRIADOMON ENGINEER DESIGNED/ALTERNATIVE
<br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION
<br /> INSTALLATION WILL SERVE: A RESIDENCE ❑ COMMERCIAL ❑ OTHER........__......_.__.__..._._—_.—_��
<br /> �y NUMBER OF LIVING UNITS;,,,,,,,,,,,,,,,,,,,,,, ___.__..._...... NUMBER OF BEDROOMS:-.............� NUMBER OF EMPLOYEES:
<br /> ar. SEPTIC TANK TYPFJMFG CAPACITY � '' gal #OF COMPARTMENTS C
<br /> ❑ GREASE TRAP TYPE/MFG _ CAPACITY _ gal #OF COMPARTMENTS
<br /> DISTANCE TO NEAREST: WELL _jj� ft FOUNDATION It PROPERTY LINE-2� -_ ft
<br /> ❑ LIFT STATION SIZE ...._.__.__.._._......-._TYPE OF PUMP Q PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM)
<br /> PL LEACH LINES LEACHING CHAMBERS #OF LINES_ LENGTH OF LINES___� It
<br /> DISTANCE TD NEAREST WELL,1�S _,_„_It FOUNDATION 10• _it PROPERTY LINE JO ft
<br /> ❑ FILTER BED WIDTH __..._._it LENGTH ---it DEPTH _....._........__it
<br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE__,J�,A
<br /> ❑ MOUNDED WIDTH__.............._
<br /> .............................It LENGTH ft DEPTH "f I►��_t
<br /> DISTANCE TO NEAREST WELL It FOUNDATION it PROPERTY LINE
<br /> ❑ SUMPS WIDTH._---.-__--_-........._.------ft LENGTH it DEPTH OI T•2 P on.,. 1t
<br /> DISTANCE TO NEAREST WELL_ it FOUNDATION __ ___It PROPERTY LM& Ulu it
<br /> ❑ DISPOSAL PONDS WIDTH It LENGTH it DEPTH-- _E� A�Uffy co"".
<br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINp�I_7N QPPA if
<br /> At SEEPAGE PITS NUMBER WIDTH ._J_ It DEPTH y}S
<br /> DISTANCE TO NEAREST WELL_L75E, it FOUNDATION-� ._--_._._.it PROPQRT'V LINE'
<br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WiT"I"l;I JOAOIIIN.,COUNTY ORDINANOtS,
<br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAOUIN COUNTY.MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 9 953-7697'
<br /> SIGNED TITLE °° _ DATEj��
<br /> 7 i
<br /> �od
<br /> /
<br /> 1 �
<br /> DEPARTMENT USE ONLY
<br /> Application Accepted Date Area Employee ID#..�
<br /> Final inspection Cj`' Date._(L, ._C ................... '1 SPECIAL PERMIT-Approved by
<br /> Character of Soil to D th of 3 Ft: Pit/Sump Soil Character:
<br /> COMMENTS/OCD L,rsY- e)?t, : D --
<br /> PE SC Received ec Amount Date Permit' Invoice# Permit 10#
<br /> Code INFO B ash Remitted Service Re ueat#
<br /> 0-3
<br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT
<br /> 4/24/12
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