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t - ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAT/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 /> Joe AoDREss 1 17,}I i� Crrr1LP <br /> CROSS STREET �ti U S�dI`I Ilr APN 0 f)AZ 7�1 PARCEL SaE <br /> OWNER NAME <br /> PHONE' <br /> I�Q/' J I �t a <br /> OWNER ADDRESS CITYISTATEMP <br /> CONTRACTOR )e%&;!,/r r��n f/'/ ✓ PHONE <br /> CONTRACTOR ADDRESS Udn„T cin/s7aTE1L <br /> 1P J ',y� <br /> LICENSE COC-42 ❑❑C-36 OTHER <br /> 11 NUMBER <br /> / EXPIRATION DATE�f� .7 <br /> WATER TABLE DEPTH: © t l ft GEOGRAPHICAL INFOR TION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION a REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> 0 REPLACEMENT - OUT-OF-SERVICE SEPTIC SYSTEM U DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: '3 NUMBER OF EMPLOYEES:- , <br /> �.SEPTIC TANK TYPE/MFG CAPACITY Irl gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal *OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ZL2,,2 ft FOUNDATION /-L ft PROPERTY LINE6!r L ft <br /> O LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 01 LEACH LINES C' LEACHING CHAMBERS #OF LINES 3 LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL//1) ft FOUNDATION �I17'1 ft PROPERTYLINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft 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 ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> *-SEEPAGE PITS NUMBER V1hOTH � I/ It DEPTH <br /> DISTANCE TO NEAREST WELL_�ft FOUNDATION ,J IJ ± 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 /> a LQUR OTICEOEQUIRED FOR INSP �1=-PLEASE CALL(209)953-769 <br /> SIGNED TITLE DATE <br /> T <br /> J <br /> EPA R rM E N7 US E 12 NLY rt� Em <br /> Application Accepted y Date Area ployee ID# Su <br /> Final Inspection By DateXf/70ZO- ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received ¢ Amount Date ParmiU Invoice# Permit ID# <br /> 77Code INFO B Remitted'` nn, Service e u <br /> �t 1 `T s1t <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4)14118 <br />