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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-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> v <br /> JOB ADDRESS CITY/ZIPC,iNf.� <br /> •j� _ '—^—T ^ <br /> CROSS STREET SDS e ss.y' APN •� J PARCEL SIZE • 'S- o <br /> Q a i <br /> OWNER NAME <br /> OWNER ADDRESS��-�✓� 12eSi t.Irv1CQ PHONE �f <br /> C C,Y �) (� CITYISTATF!Zlp L72 <br /> Ar /G <br /> CONTRACTOR �O f Llrf � A�G PHONE 1pB 4 <br /> CONTRACTOR ADDRESS d•3I t..! O�SOv+ "`IIID✓• CrrY/STATEIZIP <br /> LICENSE Gt�-42 L.' C36 OTHER NUMBER `7 S�D�S�EXPIRATION DATE .3 U- )� <br /> WATER TABLE DEPTH: r� J ft GEOGRAPHICAL INFORMATION: Coordinates X y— <br /> !-- PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION - REPAIR/ADDITION ENGINEER DESIGNED IALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: �RESIDENCE i 1 COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: L NUMBER OF BEDROOMS; NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG /�+4�riJ n� L CAPACITY jia6o gal #OFCOMPARTMENTS <br /> LI GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DSTANCE TO NEAREST: WELL /Ot) R FOUNDATION �� ft PROPERTY LINE 15-0 ft <br /> ❑ UFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS #OF LINES_ LENGTH OF LINES S5 It <br /> DISTANCE TO NEAREST WELL I(V / ft FOUNDATION dS ft PROPERTY LINE 5'D ft <br /> ❑ FILTER BED MOTH It LENGTH ft DEPTH�- ft <br /> It <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY UN <br /> ft LENGTH ,w DEPTH <br /> L3 MOUNDED WIDTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LI <br /> ❑ SUMPS WIDTH It LENGTH It DEPTH ( I It <br /> R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPER <br /> N"�(7YiCCU�.L---'R <br /> ft . <br /> C3 DISPOSAL PONDS won+ DEPTH ENt�lnn. <br /> ft LENGTH f tt ; :4I}5L <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERwt4jH <br /> WIDTH 4,9 II ft DEPTH P.5! , R <br /> SEEPAGE PITS NUMBER 3 O TY PROPERTY LINE �O R <br /> DISTANCE TO NEAREST WELL JS"O r R FOUNDATION �i O 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 24 HOUR ADVANCE NOTICE RE UIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE 4;414. la DATE <br /> S�JIQS� (Cd <br /> DEP ARDT eENT /SONLY EmployeelD# <br /> Applicat((on Accepted By Area `f <br /> is SPECIAL PERMIT-Approved by <br /> Final Inspection By Date <br /> Character of Soil to D of 3 Ft: PWSump ofl Character: <br /> COMMENTS <br /> PE SC Received hoc Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO 8 Remitted Service R uest# <br /> ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 42-01 <br /> 4/24112 <br />