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f 4 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT • <br /> SAN 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 /> JOB ADDRESS lio C \w�4 (-C.-.e CITY/ZIP \CG<Y / 537(i <br /> (1� a�►r �a�� l O l S 6 <br /> CROSS STREET \ APN / L' PARCEL SIZE • ''' <br /> C <br /> C <br /> OWNERNAME �Qe e ��`�e I PHONE <br /> OWNER ADDRESS V r VL(—C' Gr"e p CITY/STATE/ZIP <br /> CONTRACTOR T �G�.�/ (S tit f-��e C-�_ /�) PHONE rC"7' 3Z t�X0Z� <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP cr v-V,11 C t <br /> LICENSE [IFIC-42 ❑IIC-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: 7 NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> F-1REPLACEMENTOUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION C`6f(d f:Q ICtAk <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: [ NUMBER OF BEDROOMS: J NUMBER OF EMPLOYEES: <br /> C� SEPTICTANK TYPE/MFG.L If M-IS3a CAPACITY ✓oo gal #OF COMPARTMENTS <br /> /❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE 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 ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft 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 1 n ,per ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH S CUIX ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERT )/? N COl1N7�. ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH �H p Terry /4L 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 4 O R AL)VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br /> SIGNED TITLE_ (0'\ C���n V DATE ZU -2 U Z V <br /> S <br /> L <br /> r � <br /> v <br /> ( <br /> V <br /> 0 <br /> _ e <br /> DEPARTMENTUSE ONLY <br /> Application Accepted Date Area 5 Employee ID# <br /> Final Inspection By Date:5r ❑ SP CIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 F(-.' Pit/Sump Soil Character: <br /> COMMENTS ,_yn C joiA 1ns1� pC� �'y 1Vt�.lS-� r�� C� ects I -t-rc�N1 <br /> -I- also a +_ (t'c� � �_'_—��� �-���f�� � chid;n <br /> C Ir- AA o,, li'\ S h 0 r', oil 0,Jk4LIZ b.Qd�06+0'), <br /> ,A --fo <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> p CRe�t' U i0 S c� <br /> kn1��v� y-y� /� I.1 <br /> 4/18 C�C `1 30 1 �Nq�,�J �� wery W-'A'``^ (�erNlj� NSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> `l�36DO <br />