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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 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 '1 I CrrY/zv / ,-Ny <br /> CROSS STREET APN I Z IF—)t,>Q J PARCEL SD'E <br /> PHONE ���'�- J�•/�/�'7 �i'. <br /> OWNER NAME WA/�a� <br /> OWNER ADDRESS - 'icIff CITYfSTATEILPQ ..J���J YV A <br /> C" t 1 PHONE C <br /> CONTRACTOR ' (� n --_— <br /> CONTRACTOR ADDRESS (i„(�'1gilis _CITYISTATE, i Z ,fir <br /> JOLICENSE iI C-42 0"C-36 OTHER -71f "C! �]NUMBER-R;j EXPIRATION DATE ` r <br /> WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: CoordinateS X Y <br /> C1 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION - REP,URIAoorroN -" ENGINEER DESIG IAL RNATNE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: 0 RESIDENCE .7 COMMERCIAL U OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> -.?W SEPTIC TANK TYPE/MFG __ CAPACITY gal R OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG _ CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL R FOUNDATION_ f1 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 It FOUNDATION It PROPERTY LINE fl <br /> ❑ FILTER BED WIDTH It LENGTH It DEPTH h <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPFRTY LINE K <br /> ❑ MOUNDED WIDTH ^_It LENGTH 11 DEPTH it <br /> DISTANCE TO NEAREST WELLII =OUNDATIOFI N PROPERTY LINE it <br /> • SUMPS WIDTH It LENGTH It DEPTH _R <br /> DISTANCE TG NEAREST WELL It -OUNDATION fl PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUMOATION It PROPERTYLINE _ It <br /> ❑ SEEPAGE PITS NUMBER WIDTH—-— fl DEPTH It <br /> DISTANCE TC NEAREST ::ELL It =OUNDATION It PROPERTY LINE it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SwNE TITLE� DATE <br /> fill I <br /> DEPA PTMW, -1 <br /> NLY cmployeelD:_ /' RF y�ENT <br /> Application Accepted By DateArea 1 i <br /> Final Inspection By _ Date '7 SPECIAL PERMIT-Approved by _ Y1eD <br /> Character of Soil to Depth of 3 Ft: _ PiUSump Soil Character: (, : Q <br /> COMMENTS 41' 4 11 /J 6 ?0?4 <br /> '(7tC rpt Fz2eem /t'l _i ctC. Y >: et7 E iciAQUIN <br /> Hct'IT✓.M • 0-Ny I-&xs as , )A �'4s" ��Ty <br /> -- PE SC Received eck# Amount Date Permit/ I�ae# Permit ID# -"T 1 M <br /> Code INFO e Remitted Service Request# SVT <br /> wevIN <br /> !' istu - <br /> 42-0i ONSITE WASTEWATER TRTUNT SYSTEM PERMIT <br /> 4TI4118 <br />