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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN Cp`p-/�q�� ENTAL HEALTH DEPARTMENT 1668 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)46&3420 <br /> NON-REFUNDPBLE P CALL(20V 953-7697FOR INSPECTIONS L EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP 54te-6 V 401 c a <br /> r Q 7-0 TTTTTTTT '-J^c ; <br /> CROSS STREET �Ws�`e APN 45 V1 r"' �5� PARCEL SIZE�j.�.__�[(� <br /> C <br /> OWNER NAME �Ir--V�,y (� `—PHONE- <br /> OWNER <br /> H NEOWNER ADDRESS .�tl 1 G�� �� �L.W CITY/STATE/ZIP 1 • 7 �¢�'�I / ,, -y� <br /> CONTRACTOR PHONE :)Os <br /> CONTRACTOR ADDRESS7%,� � CIT//STATE21P � <br /> ❑ <br /> LICENSE C-42 OC-36 OTHER?f,+ NUMBER� Z 52 57 EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT#-17 <br /> 00 LAND USE APPLICATION# <br /> ' TYPE OF WORK: NEW INSTALLATION F REPAIRIADDITION ENGINEER DESIGNED lALTERNATI E <br /> J REPLACEMENT Cl OUT-OF-SERVICE SEPTIC SYSTEM 1 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE OMMERCIAL ❑ OTHER_ <br /> NUMBER OF LIVING UNITS: aa NUMBER OF BEDROOMS: ' NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG P. L, . CAPACITY -?._00 gal #OF COMPARTMENTS 7 <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ' DISTANCE TO NEAREST: WELL it FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES f i LEACHING CHAMBERS _ #OF LINES Z— LENGTH OF LINES it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ FILTER BED WIDTH It LENGTH (t DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE it <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH N <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELLR FOUNDATION 1t PROPERTY LINE it <br /> ❑ DISPOSALPONDS WIDTH ft LENGTH it DEPTH It <br /> ' DISTANCE TO NEAREST WELLit ffUNDATION (t PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER Z^- WIDTH 3t if DEPTH Z C' ft <br /> DISTANCE TO NEAREST WELL*,) ft FOUNDATION it PROPERTY LINE it <br /> t 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 24 H01IR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> � SIGNED TITLE_ 044!nt !' _ DATE <br /> FT-1- y- t <br /> C !. r <br /> J4 All' <br /> Ir- <br /> ! Arr i I Tld <br /> Si <br /> N <br />