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occf) F31��t�_ Pc_-wu� <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUND BLE PERM T CALL 09 953-7697FOR INSPECTIONS EXPIRES 1 YEAR IFROM DATE ISSUED <br /> JOB ADDRESS _ CITY/ZIPC V <br /> CROSS STREET i��PN_�L1 ! PARCEL SIZE/�OWNER NAMEC, l �+ - PHONE •'3 I V� P. <br /> OWNER ADDRESS S^-t C— n , j� }� CITY/STATE/ZIP <br /> CONTRACTOR D'A - PKS W / 0t-45 JVG PHONE- <br /> CONTRACTOR ADDRESS4(�00 CITY/STATE/ZIP <br /> LICENSE (C-42 7C-36 OTHER_ _ _ NUMBER I i 1_ I EXPIRATION DATE__ 11115 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INrORMATION: Coordinates X Y _ <br /> PERC TEST # l BUILDING PERMIT# _ _ LAND USE APPLICATION#_ <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DES I /AL ERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM SIC DESTRUCTION �_F- <br /> INSTALLATION WILL SERVE: +y "�C RESIDENCE L) COMMERCIAL OTHER <br /> 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 ft FOUNDATION It PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE _ TYPE OF PUMP .. _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES 1CLEACHING CHAMBERS_ Q �F— #OF LINES 1 LENGTH OF LINES �0 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION _ ft PROPERTY LINE_ yam ft <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL _ it FOUNDATION ft PROPERTY LINE ft <br /> SUMPS WIDTH -- _ ,- ft LENGTH c I It DEPTH 19-C It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE cJ" It <br /> O DISPOSAL PONDS WIDTH ft LENGTH_ It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL_ - ft FOUNDATION It 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 /> QI*M4 H U T E REQUIRED FOR I SON -IZLEASE CALL 209 953-7697 <br /> SIGNS AJU TITLE CAk _— DATE — J- I <br /> -t_ A41 <br /> y� <br /> L xn- 3 r R $k Y _ Rr G+Ft <br /> 110 <br /> Illy <br /> I I I I I I QI I <br /> DEPARTMENT USE ONLY <br /> Application Acce y94 Date__ 416114t Area IrD ��I Employee ID# fseo <br /> Final Inspection Date / [ISPECIAL PERMIT-Approved by <br /> Character of Soil to/ epth of 3 Ft: it/Sump Soil Character: <br /> COMMENTS ,� I- / cN Lr 1 e-t bcwv �;y. ltitc <br /> 0dLW(_j, :110 1�1 C&4 �;f3/LK .t f'eTlchs <br /> PE SC Received Che Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> Zi It �L ? 2 S;eoo �y <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />