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pb ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> N—ON REFUNDf RLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> r - 17i[� /c <br /> JOB ADDRESS -t O — 6 <br /> CITY <br /> /Z <br /> IP <br /> CROSS STREET J kT�J� APN �G/ V /� PARCEL SIZE y <br /> v <br /> OWNER NAME ACV 6f s I/V PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP ;]41e <br /> CONTRACTOR . PHONE CZ 09) Z S •3d h9 t �I , <br /> CONTRACTOR ADDRESSy V sy u�1C<� 4L,4 -J rC,C CITY/STATE/ZIP <br /> LICENSE AC-42 •_C-36 OTHER NUMBER �ct} 7J EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> i <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION 7—REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT i DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF,,BEDROOMS: �y� NUMBER OF EMPLOYEES: � 3 <br /> O D <br /> SEPTIC TANK TYPE/MFG em <br /> 046, eo tAf t-��'"^�-CAPACITY 4/ cop gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG f U\ CAPACITY _ gal #OF COMPARTMENTS} <br /> DISTANCE TO NEAREST: WELL t ft FOUNDATION ft PROPERT ( <br /> Y L'NE C r 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 It 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 It <br /> I <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEA EST WELL -, �f FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NuMBER WIDTH �/G _ ft DEPTH 2 <br /> DISTANCE TO NEAREST WELL ASO -f ft FOUNDATION ft PROPERTY LINE 1 O ft <br /> 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. A/� <br /> INI H ADV E NOTICE REQUIRED FOR INSPECTIONS-PLEASE BALL(2�-7 <br /> TITLE DATE <br /> SIGNED / <br /> Kc <br /> 1 <br /> ——-- <br /> DA VIA <br /> E <br /> f{ <br /> DEPARTMENT LIE O Y <br /> Application Accu Date Area Employee ID# <br /> Final Inspection B Date 0 SPECIAL PERMIT-Approved by <br /> Character of Soil to of 3 Ft: Pit/ ump Soil Character: <br /> COMMENTS - 4 <br /> A4wer I LsefozAj- -- <br /> -D <3 � c <br /> PE SC Received Amount Date Permit/ Invoice# Permit IDN <br /> Code INFO Cash Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 1014/07 <br />