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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS ��^Q��E�'�XPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 73DO DFL 7A ,�.}/E. CITYIZIP�, / 9,5,1?04 <br /> CROSS STREET 7 � 6dIM9 APN 213-020-30,Al PARCEL SIZE TQ• �i <br /> OWNER.NAME Na VU FA,941i PHONE _ ? <br /> OWNERADDRESS 1300 DELT CIN/STATEIZIP MgLILV <br /> CONTRACTOR OKF-5 F-y !'o�ISULT/�/G PHONE GSD 474,-96gJ <br /> CONTRACTOR ADDRESS F49-00K 37.'74( / CITY/STATE/ZIP TI{R LOCILr CA f szef <br /> LICENSE BIC-42 OfIC-36 OTHER t"F-L /YT71 NUMBER EXPIRATION DATE to <br /> WATER TABLE DEPTH: N fl GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST #J BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION q REPAIR/ADDITION ENGINEER DOSIGNED(ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE 11 COMMERCIAL O OTHER <br /> l NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL it FOUNDATION it PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 0 LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES it <br /> DISTANCE TO NEAREST WELL it FOUNDATION fl PROPERTY LINE R <br /> ❑ FILTER BED WIDTH it LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> O MOUNDED WIDTH It LENGTH 0 DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION 0 PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> O SEEPAGE PITS NUMBER WIDTH 0 DEPTH ft <br /> DISTANCE TO NEAREST WELL R 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 /> N 4 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 20 6 7 <br /> SIGNED TITLE CIVIL/NE`/Z DATE s/=� <br /> RONMC U <br /> kILTH DEPARTMEN - <br /> i <br /> ARTMENT IISE LY <br /> Application Accepted By Date Area Employee IDN <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 P' Sump Soil Character: <br /> COMMENTS „ Pn k. � I✓L <br /> PE SC Received 1 Amount Date Permit/ invoice# Permit ID# <br /> Code INFO8 Cash Remitted Service Re uest# <br /> 3s tS Z <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114113 <br />