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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> fSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ( JOB ADDRESS Y 33 CITY/ZIP orf3 In `n <br /> ICROSS STREET �k7%A`^ ¢2�y, r APN L-- `--�' Z/O- n PARCEL SIZE .�L-O O e <br /> 1` o <br /> OWNER NAME / �-2 <br /> "=-`-� ��� �� PHONE � <br /> OWNER ADDRESS ^ CfTY/STATEJZIP <br /> CONTRACTOR �"H PHONEU <br /> CONTRACTOR ADDRESS �� I�T,I./ S 7 CITYISTATFJZIP /a <br /> 4c,y -S 3 <br /> 7I LICENSE C,.0-42 )4-36 OTHER ALS NUMBER EXPIRATIoN DATE <br /> I <br /> f WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> G PERC TEST # i BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: 0 NEW INSTALLATION 0 REPAIR/ADDITION G ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT - OUT-OF-SERVICE SEPTIC SYSTEM -1z DESTRUCToN <br /> INSTALLATION WILL SERVE: D RESIDENCE -- COMMERCIAL C OTHER <br /> NUMBER IF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACr-Y gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DHSTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES �j LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft r <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTERSED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH k <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE h <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft r <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R x <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R S <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft ` <br /> DISTANCE TO NEAREST WELL ft FOUNDATION �ft~- PROPERTY IJNE ft r` <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 /> M M 24 v E NOTICE REQUIRED FOR INSP�FCTIONS-PLEASE CALL(209)95377697/ <br /> SIGNED �/ — TITLE �A�-�-'a DATE <br /> I <br /> I Aa <br /> I <br /> I <br /> PAR; <br /> ;:rnl I <br /> I <br /> I <br /> DEPARTMENT SEONLY S <br /> APDlicatioi0`A4cepted - .—. Data �!1 I Ivf fly` �---,.grey�. -.._,-,y EmployeA ID# <br /> "Final Inspection By - — Oate %? "�] SPECI%11 P1=RNlIT=Ap roved 6y <br /> Character of Soil to Depth of 3 Pit/SSump Soil Character: <br /> COM /TS 2EF: ca03otIfL <br /> PE SC Received CChociM Amount ParmIV <br /> Irnoice# Permit ID# <br /> Code INFO 8 Remitted ' Date I Services Request# <br /> you I ��� Sfrz Io.57 f ! SIL 00 6fq-e-I- <br /> I <br /> 42101 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> (Y28l09 <br />