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Y/' • <br /> 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 C CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS � �f7�U -2/Al S F��/`/ 7 �CIITTTYIIZIP( <br /> CROSS STREET \llh✓)w/ APN1/(�/�i�/ - " PARCEL SIZE p <br /> J e, n d <br /> OWNER NAMEIFpIJSG <0/�S PHONE ��/ 37V '7 <br /> /�.� <br /> OWNER ADDRESS /`��/"! � . / CITY/STATE/ZIP <br /> CONTRACTOR �Crl/7c. J�/�✓J mtc 5C4, PHONE .3 C,7-Z. 7 <br /> CONTRACTOR ADDRESSy�/C� ��SIJbc/ �✓L CITY/STATE/ZIP L.� p <br /> LICENSE ❑X--42 110C-36 OTHER NUMBER % S/�`��EXPIRATION DATE O ■ IVIED <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y (" <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION#S <br /> TYPE OF WORK: u NEW INSTALLATION -r411ANWADDITION LJ ENGINEER D ^�+rMVI <br /> El ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTIO ' i SEP <br /> INSTALLATION WILL SERVE: +--RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY ��o�> gal #OF COMPARTMENTS Z <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 — Sz ft <br /> DISTANCE TO NEAREST WELL /S'U ft FOUNDATION ft PROPERTY LINE d / 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 TON AREST L ft FOUNDATION ft PROPERTY LINE ft <br /> Q(- SEEPAGE PITS NUMBER WIDTH 36" ft DEPTH '271ft <br /> DISTANCE TO NEAREST WELL, O ft FOUNDATION SD ft PROPERTY LINE !i 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 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED — TITLE C� �YrC�� DATE w/'3%/'v <br /> V� <br /> d <br /> 0 <br /> w <br /> 3- a <br /> A R TMEN T M Q OdI.Y <br /> Application Accepted ByDate Area Employee ID# <br /> Final Inspection By #elS-6-LM Date Cr ❑ 0�— <br /> by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump <br /> COMMENTS <br /> PE SC Received tgaW Amount Permit/ <br /> Code INFO B emitted Date Service Request# Invoice# Permit ID# <br /> 7 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />