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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 <br /> 2y09 9531-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1�n,UA `,�-rI CITY/ZIP <br /> CROSS STREET A.����r�' VJ:\`) APN �'J �- �O"tt1� r?''"`1 PARCEL SIZE <br /> OWNER NAME�Zyts Y� (-'_ ���,,r-✓N PHONE <br /> I Z � <br /> OWNER ADDRESS I J�+=.' fjpG Iv, L V1 CITY/STATE/ZIP tl�) GLt 6�<�`J <br /> CONTRACTOR I �• �'� L.n-r rL l 1. PHONE C))[, r6`T O!7(-.� <br /> CONTRACTOR ADDRESS ��r O'� !r�"' f I Jt— CITVfS7ATElZIP L-t/'� <br /> LICENSE C-02 C-36 OTHER (� y I NUMBER L•7 f�` -EXPIRATION DATE 11 1 / J <br /> 6f 11 J <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> �( PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL <br /> OTHER - -`�,, <br /> NUMBER OF LIVING UNITS: � NUMBER OF BEDROOMS: CT- NUMBER OF EMPLOYEES--±t' <br /> SEPTIC TANK TYPE/MFG U CAPACII --7 'IV'-'" gal #OF COMPARTMENTS --t- <br /> ❑ GREASETRAP 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 c ft <br /> DISTANCE TO NEAREST WELL '� ft FOUNDATION ft PROPERTY LINE —'r Cl R <br /> ❑ FILTERBED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY L INF ft <br /> ❑ MOUNDED WIDTH It LENGTH It 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 ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <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 8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 Z( '' <br /> SIGNED ./ TITLE FY` / DATE $ <br /> PA <br /> G 3 202 <br /> QU/,V <br /> rAfelVT <br /> DEPA RTMENT,U4ij OjVLY <br /> Application Accepted By /`— Z—' Date Area •> <�`) Employee ID# �J <br /> Final Inspection By / y/Lt"_A Date SPECIAL PERMIT-Approved by <br /> Character of Soil to De th of 3 Ft: P t/Sump Sall Character: <br /> COMMENTS <br /> P±'T C -�r s->` :u� I L& 2", <br /> PE Sc Received Check#/ Amount Dae Permit/ Invoice# Permit ID# <br /> Code INFO Cas Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 411411 B <br />