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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-REFUNDABLEH-1-0PERMIT CALL(2,,09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,1 <br /> JOB ADDRESS I ►�^l VV-I y\k� � /T� CITY/ZIP )MCA. ' <br /> CROSS STREET I ] I APIN 2= PARCEL SIZE `/ o <br /> /� <br /> ,ft c <br /> OWNER NAME ( —t &4r v r PHONEp 1<33J?q - 7 <br /> OWNER ADDRESS �� IG� r^ CITY/STATE/ZIP IO gazq9 _ `ILl G <br /> CONTRACTOR �( (�� rum�' L L` l n r PHONE 'JL—C)� C(�� C)&()& <br /> CONTRACTOR ADDRESS 1-I co �//. IOW / Y rt,rt � ll CITY/STATE/ZIP � ��1i�^ c A- I�y <br /> J z S <br /> LICENSE ❑f C-42 ❑I C-36 OTHER LIZ` NUMBER -N���d EXPIRATION DATE 3 /31 rull6 u LD <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALLTE�RNATIVE <br /> J <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM t'y DESTRUCTION Z4.W%V-S <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft 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 R ADVANCE NOTICE REQUIRED FOR IN PEC_TIIQNS - PLEASE ALL 20 953-7697 <br /> E / <br /> SIGNED TITLE � C.r/ DATE 3/ / <br /> E Q N <br /> M Er <br /> D PARTMENTUSE NLY <br /> Application Accepted Date OArea I� Employee ID# I <br /> Final Inspection By Date 72 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump S99il Character: <br /> COMMENTS FlWa,d A6 uc Y— Yr^of a/ <br /> < < <br /> PE SC Received Amount Date PermiU Invoice# Permit ID# <br /> Code INFO By ash Remitted Service Request <br /> euest# <br /> 42-01 V <br /> ONSITE WASTEWATERMNTSYM PERMIT4/14!18 �� � rlt4' <br /> Ll <br /> (A"� 3 d�ra- Eo 2 N 1 3 t o <br />