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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 9520$-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPEC77ONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYZP 4 . <br /> CROSS STREET �• 9r n APN 1l Ll I -0'0 1 PARCEL SIZE s Tj <br /> OWNER NAME ���31_T Q' yn f� T PHONE <br /> OWNER ADDRESS Q n to t4-A S P e%�^• +-� CITYISTATEIZIP <br /> CONTRACTOR �•�LS ,� `GI'G �( y.r y�jet y PHONE (✓A'�-rY -S <br /> CONTRACTOR ADDRESS A"' �_Gr S, CITYISTATEZP �'�t**."_•'t�'`Gr%'s'�' �" 4—,'s�''G:* <br /> LICENSE LTJ.: C-42 C-36 OTHER ^- NUMBER gEXPIRATION DATET D <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> L! PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT -- OUT-OF-SERVICE SEPTIC SYSTEM _ DESTRUCTION <br /> INSTALLATION WILL SERVE: �ESIOENCE COMMERCIAL !.: OTHER <br /> NUMBER OF WING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> t�—SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG C CAPACITY 981 #OF COMPARTMENTS y� <br /> DISTANCE TO NEAREST: WELL / ft FOUNDATION I a ft PROPERTY LINE �—J 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 It <br /> .,,DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> FILTER BED+K WIDTH l S ft LENGTH <br /> � "7 ft DEPTH <br /> .DISTANCE <br /> .DISTANCE TO NEAREST WELLG0 PROPERTY <br /> ROPERTY LINE fftt` <br /> ft FOUNDATION 4 A-4 <br /> ❑ MOUNDED WIDTH It LENGTH f ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS MOTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <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 /> MINIMUM 24 O R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE �✓w��'f'%� "�^'"/"u DATE <br /> Iyn m <br /> r� <br /> ire F� <br /> O , <br /> 3 <br /> Z j <br /> I 1 iy <br /> _�._. <br /> } � DEPARTMENT USEDNL i/i )I <br /> Application Accepted Data Area t% — Employee IO#� <br /> Final Inspection By Date SPECIAL PERMIT-Approved by <br /> Character of Soil to DO IP3 h of 3 Ft: Pitisump oil C aracter: <br /> COMMENTS <br /> PE SC Received Check#/ Amount i PermiU <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit!D# <br /> d 7 SP-00 2 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4124112 <br />