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I <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA TMENT=:;_--- - ----. E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> J <br /> NON-.REFUNDABLE PERMIT 99 CALL-2-09-95-3{-7697 FOR INSPECTIONS %7 EXPIRES 1 YEAR F�R�OM TDATE ISSUED <br /> B ADDRESS - CTFY/ZIP A y GGr4^^'7 ( , lam' L. <br /> j <br /> CROSS STREET -�'�`" GTiAPN �. ?-/ Gt^P t7 C7 t^'� PARCEL SIZE >I o <br /> 01 <br /> j <br /> /-\ �y-� � <br /> OWNER NAME EL .4 S l: °/ ac--A "P ( 67 PHONE 6 J � /�Gi fi7 <br /> --'PWNER ADDRESS G7 L V�yCG�.d. CITY/STATE/ZIP i" J <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION A GG✓ �-' <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL THER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE It <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 PROPERTYLINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE 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 /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSALPONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT IHAVE PREPARED,THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> -STATE LA ND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> M 2F10GR AD NO <br /> . ICE REQUIRED FOR INS IONS-PLEASE CALL 209 953-7697 <br /> I <br /> i <br /> /A� DEPARTMENT US ONLY _ <br /> Application Accepted By" J.� J .Ywcti Date Area OS qj Employee ID#_*w_F� <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft:7 Pit(Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO By Cash Rem tte4 Date Service Re uest# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />